Provider Demographics
NPI:1811259096
Name:ADEDIRAN, SAMUEL GBOYEGA (MD,)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GBOYEGA
Last Name:ADEDIRAN
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-7050
Practice Address - Fax:864-560-0800
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101264136207RH0003X
PAMT201305207RH0003X
SC86536207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC865362Medicaid
SCSCL0183365OtherMEDICARE PIN
SCSCL0184746OtherMEDICARE PIN