Healthcare Provider Details

I. General information

NPI: 1528011889
Provider Name (Legal Business Name): SAMUEL N. CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

10000 BAY PINES BLVD BLDG. 100, 4C-100
BAY PINES FL
33744
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2505
  • Fax: 706-721-1500
Mailing address:
  • Phone: 727-398-6661
  • Fax: 727-319-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number046944
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: