Healthcare Provider Details

I. General information

NPI: 1154011567
Provider Name (Legal Business Name): BLAIN ANTHONY SAMUELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 53RD AVE
BETTENDORF IA
52722-6279
US

IV. Provider business mailing address

2140 53RD AVE
BETTENDORF IA
52722-6279
US

V. Phone/Fax

Practice location:
  • Phone: 563-421-5700
  • Fax:
Mailing address:
  • Phone: 563-421-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-56075
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: