MEDICARE: SAMANTHA S WYATT 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	207N00000X	Dermatology Physician	00026547	AL

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
2	51001088	OTHER	AL	BCBS AL PROVIDER#
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942247150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA S WYATT M.D.

Provider Business Mailing Address
First Line	:	620 WALNUT ST NE
Second Line	:	SUITE A
City	:	DECATUR
State	:	AL
Zip	:	35601-2456
Country	:	US
Telephone Number	:	256-353-7775
Fax Number	:	256-353-7765

Provider Business Practice Location Address
First Line	:	620 WALNUT ST NE
Second Line	:	SUITE A
City	:	DECATUR
State	:	AL
Zip	:	35601-2456
Country	:	US
Telephone Number	:	256-353-7775
Fax Number	:	256-353-7765

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	12/18/2013

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