Healthcare Provider Details

I. General information

NPI: 1326151028
Provider Name (Legal Business Name): SAMSON GARY SERBIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6036 NORTH 19TH AVENUE SUITE 400B
PHOENIX AZ
85015-2110
US

IV. Provider business mailing address

6036 NORTH 19TH AVENUE SUITE 400B
PHOENIX AZ
85015-2110
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-2520
  • Fax: 602-242-7625
Mailing address:
  • Phone: 602-242-2520
  • Fax: 602-242-7625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number17526
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: