Provider Demographics
NPI:1700813094
Name:SAMUEL J KING MD
Entity type:Organization
Organization Name:SAMUEL J KING MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:606-432-9400
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-1107
Mailing Address - Country:US
Mailing Address - Phone:606-432-9400
Mailing Address - Fax:
Practice Address - Street 1:419 TOWN MOUNTAIN RD
Practice Address - Street 2:PROFESSIONAL ASSOCIATES BUILDING, SUITE #204
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1631
Practice Address - Country:US
Practice Address - Phone:606-432-9400
Practice Address - Fax:606-432-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64227903Medicaid
KY1393401Medicare PIN