Provider Demographics
NPI:1962621995
Name:SAMUEL TAYLOR, M.D.
Entity type:Organization
Organization Name:SAMUEL TAYLOR, M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-242-6677
Mailing Address - Street 1:PO BOX 2737
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-2737
Mailing Address - Country:US
Mailing Address - Phone:229-242-6677
Mailing Address - Fax:229-242-1870
Practice Address - Street 1:2601 BEMISS RD
Practice Address - Street 2:SUITE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1445
Practice Address - Country:US
Practice Address - Phone:229-242-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22479207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00261049DMedicaid
GA00261049DMedicaid