Provider Demographics
NPI:1316902901
Name:SAMUEL, GEORGE P (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:P
Last Name:SAMUEL
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:PO BOX 989
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0989
Mailing Address - Country:US
Mailing Address - Phone:573-778-0020
Mailing Address - Fax:573-776-7548
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1274
Practice Address - Country:US
Practice Address - Phone:573-996-7148
Practice Address - Fax:573-996-4041
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5B21207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO188260OtherBLUE CROSS BLUE SHIELD
MO201563616Medicaid
E19632Medicare UPIN
MO188260OtherBLUE CROSS BLUE SHIELD