Provider Demographics
NPI:1194932301
Name:SAMSON, CHARLES MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:SAMSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-454-6173
Mailing Address - Fax:844-231-8912
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED GASTRO, HEPATOLOGY AND NUTRITION
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6173
Practice Address - Fax:844-231-8912
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019875208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204405104Medicaid
MO1194932301Medicaid