Provider Demographics
NPI:1356367254
Name:PAULINE M. SAMUELS, M.D., PC
Entity type:Organization
Organization Name:PAULINE M. SAMUELS, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-394-6666
Mailing Address - Street 1:3712 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-3505
Mailing Address - Country:US
Mailing Address - Phone:610-394-6666
Mailing Address - Fax:610-394-6667
Practice Address - Street 1:3712 GARRETT RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-3505
Practice Address - Country:US
Practice Address - Phone:610-394-6666
Practice Address - Fax:610-394-6667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD956958L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAAETNAOther0561
PAKEYSTONEOther2147326001
PA0016036540005Medicaid
PA8240OtherELDERHEALTH
PA=========OtherCOMMERCIAL INSURANCE
PAAETNAOther0561
PAG17825Medicare UPIN