Provider Demographics
NPI:1962423012
Name:GBENGBE, SAMUEL (PA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:GBENGBE
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 1:3317 HILLSMERE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5607
Mailing Address - Country:US
Mailing Address - Phone:410-627-0833
Mailing Address - Fax:
Practice Address - Street 1:6655 SYKESVILLE RD
Practice Address - Street 2:SPRINGFIELD HOSPITAL CENTER
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-7966
Practice Address - Country:US
Practice Address - Phone:410-970-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant