Healthcare Provider Details

I. General information

NPI: 1851664932
Provider Name (Legal Business Name): SAMUEL LOUIS FENICHEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 S. MARINA PACIFICA DR
LONG BEACH CA
90803
US

IV. Provider business mailing address

5203 S. MARINA PACIFICA DRIVE
LONG BEACH CA
90803
US

V. Phone/Fax

Practice location:
  • Phone: 562-431-5750
  • Fax: 562-431-5750
Mailing address:
  • Phone: 562-431-5750
  • Fax: 562-431-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberGFE16337
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: