Provider Demographics
NPI:1548472194
Name:SAMPLE, WILLIAM R JR (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:SAMPLE
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 E CARSON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203-1835
Mailing Address - Country:US
Mailing Address - Phone:412-381-4422
Mailing Address - Fax:412-381-8503
Practice Address - Street 1:1927 E CARSON ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203-1835
Practice Address - Country:US
Practice Address - Phone:412-381-4422
Practice Address - Fax:412-381-8503
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006142L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA479579Medicare UPIN
PA036524Medicare ID - Type UnspecifiedMEDICARE