Provider Demographics
NPI:1891778254
Name:BAILEY, SAMUEL A (PA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:BAILEY
Suffix:
Gender:M
Credentials:PA
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 66971
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63166-6971
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85001646363A00000X
IL085-001646207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001646OtherBLUE SHIELD
IL085001646OtherBLUE SHIELD
ILK48951Medicare PIN
ILK48333Medicare PIN
ILK12351Medicare ID - Type Unspecified