Provider Demographics
NPI:1972538841
Name:CHAN, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CHAN
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 1:11116 MEDICAL CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 150
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6755
Practice Address - Country:US
Practice Address - Phone:301-665-4825
Practice Address - Fax:301-665-4826
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD36655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDW111OtherFEDERAL EMPLOYEES PROGRAM
MDKDZ2OtherCAREFIRST BLUECROSS BLUES
MD283231300Medicaid
MDCJ4601OtherRAILROAD MEDICARE
MD824211OtherMAMSI
MDW111OtherFEDERAL EMPLOYEES PROGRAM
MD824211OtherMAMSI