Provider Demographics
NPI:1902270283
Name:SAM, PHALY II (MS)
Entity Type:Individual
Prefix:MS
First Name:PHALY
Middle Name:
Last Name:SAM
Suffix:II
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NONE
Mailing Address - Street 1:3530 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807
Mailing Address - Country:US
Mailing Address - Phone:562-424-1886
Mailing Address - Fax:562-424-2296
Practice Address - Street 1:3530 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4569
Practice Address - Country:US
Practice Address - Phone:562-424-1886
Practice Address - Fax:562-424-2296
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95747409E13032Medicaid