Provider Demographics
NPI:1275633844
Name:SIM, SAMUEL K (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:K
Last Name:SIM
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 1:3250 SE 164TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9313
Mailing Address - Country:US
Mailing Address - Phone:360-946-4313
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT129513207RG0100X
MIEMC0004965207RG0100X
HIMD-12112207RG0100X
WAMD00032743207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000237701OtherHMSA BILLING NUMBER
HI519043-01Medicaid
WA8179897Medicaid
HIH54976Medicare PIN
G8880013Medicare PIN
HI519043-01Medicaid
HI0000237701OtherHMSA BILLING NUMBER