MEDICARE: SAMUEL JOSHUA CREEKMORE III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	06178	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578538591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL JOSHUA CREEKMORE III M.D.

Provider Business Mailing Address
First Line	:	216 OXFORD RD
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-3115
Country	:	US
Telephone Number	:	662-534-9042
Fax Number	:	662-534-9707

Provider Business Practice Location Address
First Line	:	216 OXFORD RD
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-3115
Country	:	US
Telephone Number	:	662-534-9042
Fax Number	:	662-534-9707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	07/08/2007

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