Provider Demographics
NPI:1528052297
Name:SAMUEL, CHANDY C (MD)
Entity type:Individual
Prefix:
First Name:CHANDY
Middle Name:C
Last Name:SAMUEL
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 1:3625 QUAIL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-8881
Mailing Address - Country:US
Mailing Address - Phone:620-221-6100
Mailing Address - Fax:620-221-7680
Practice Address - Street 1:3625 QUAIL RIDGE RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-8881
Practice Address - Country:US
Practice Address - Phone:620-221-6100
Practice Address - Fax:620-221-7680
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0416859208600000X
KS04-16859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100085170AMedicaid
KS002162Medicare PIN
KS004052005Medicare PIN
KSB68680Medicare UPIN