Provider Demographics
NPI:1841253267
Name:CHAN, SAMUEL S (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SHEUNG-KWUN
Other - Middle Name:SAMUEL
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:202 CANAL ST
Mailing Address - Street 2:SUITE 801
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4517
Mailing Address - Country:US
Mailing Address - Phone:212-406-2301
Mailing Address - Fax:212-406-2359
Practice Address - Street 1:202 CANAL ST
Practice Address - Street 2:SUITE 801
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4517
Practice Address - Country:US
Practice Address - Phone:212-406-2301
Practice Address - Fax:212-406-2359
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193850-1207RC0000X, 246XC2901X, 246X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246X00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist Cardiovascular
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes246XC2901XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularCardiovascular Invasive Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03543166OtherMEDICAID-GROUP PROVIDER (DOCTOR CHAN MEDICAL PRACTICE, PC)
NY01617692OtherMEDICAID-INDIVIDUAL PROVIDER
NY03543166OtherMEDICAID-GROUP PROVIDER(DOCTOR CHAN MEDICAL PRACTICE, PC)
NY1376729426OtherNPI-GROUP ORGANIZATION
NY1841253267OtherNPI-INDIVIDUAL PROVIDER
NY1376729426OtherGROUP NPI (DOCTOR CHAN MEDICAL PRACTICE, PC)
NY1841253267OtherINDIVIDUAL NPI
G20217Medicare UPIN