Provider Demographics
NPI:1548259617
Name:DETWILER, SAMUEL T (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:DETWILER
Suffix:
Gender:M
Credentials:DO
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 1549
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16003-1549
Mailing Address - Country:US
Mailing Address - Phone:724-284-4084
Mailing Address - Fax:724-284-4144
Practice Address - Street 1:160 MEDICAL CENTER RD STE A
Practice Address - Street 2:
Practice Address - City:CHICORA
Practice Address - State:PA
Practice Address - Zip Code:16025-2612
Practice Address - Country:US
Practice Address - Phone:833-995-0123
Practice Address - Fax:724-445-7446
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7985207Q00000X
PAOS016525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH753111223027OtherCARESOURCE
OH000000285856OtherANTHEM BCBS
OH2393299Medicaid
OH000000285856OtherUNICARE-LIFE AND HEALTH
OHP006463OtherGATEWAY HEALTH PLAN OF OH
OH4489898OtherCIGNA
OHJ07985OtherSUMMACARE HEALTH PLAN
OHP006463OtherGATEWAY HEALTH PLAN OF OH
OHJ07985OtherSUMMACARE HEALTH PLAN
OHP00036310Medicare ID - Type UnspecifiedRAILROAD MEDICARE