Healthcare Provider Details

I. General information

NPI: 1396988184
Provider Name (Legal Business Name): MICHAEL JOSEPH SAM IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SWRMC 3601 WOMBLE ST
SAN DIEGO CA
92136-0001
US

IV. Provider business mailing address

3601 WOMBLE ST
SAN DIEGO CA
92136-0001
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-6641
  • Fax: 619-556-9617
Mailing address:
  • Phone: 619-556-6641
  • Fax: 619-556-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP0900513
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: