Healthcare Provider Details

I. General information

NPI: 1619071826
Provider Name (Legal Business Name): WILLIAM OLIVER SAMUELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 PIERCE ST STE 101
SIOUX CITY IA
51104
US

IV. Provider business mailing address

2800 PIERCE ST STE 101
SIOUX CITY IA
51104
US

V. Phone/Fax

Practice location:
  • Phone: 712-224-8677
  • Fax: 712-277-1662
Mailing address:
  • Phone: 712-224-8677
  • Fax: 712-277-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number26070
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: