Provider Demographics
NPI:1952374498
Name:AGNEW, SAMUEL G (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:AGNEW
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 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:309 N MANGOUSTINE AVE UNIT G
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1098
Practice Address - Country:US
Practice Address - Phone:321-363-1754
Practice Address - Fax:321-363-3336
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22674207X00000X
MI4301102465207XX0801X
FLME102967207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I209904Medicare PIN
TN103I200302Medicare PIN
FL27817WMedicare PIN
AL102I209902Medicare PIN