Healthcare Provider Details

I. General information

NPI: 1497288773
Provider Name (Legal Business Name): SAMUEL HOUSTON PAYNE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 PEACHTREE RD NE STE 500
ATLANTA GA
30309-1446
US

IV. Provider business mailing address

2061 PEACHTREE RD NE STE 500
ATLANTA GA
30309-1446
US

V. Phone/Fax

Practice location:
  • Phone: 404-352-3522
  • Fax:
Mailing address:
  • Phone: 404-352-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number85620
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number85620
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: