Provider Demographics
NPI:1316476823
Name:PRICE, SAMUEL N (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:N
Last Name:PRICE
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 1:612 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 W TYSON ST STE 1A
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:IN
Practice Address - Zip Code:47042-8036
Practice Address - Country:US
Practice Address - Phone:812-689-5101
Practice Address - Fax:812-689-6199
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125070950207Q00000X
IN02005959A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300038188Medicaid
KY7100664390Medicaid
KY7100664390Medicaid