Healthcare Provider Details

I. General information

NPI: 1831156595
Provider Name (Legal Business Name): SAMUEL L. ZUCKERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 12/10/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MOUNTAIN NEONATOLOGY LLC 3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

V. Phone/Fax

Practice location:
  • Phone: 602-346-7013
  • Fax:
Mailing address:
  • Phone: 210-737-4928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberJ9854
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberJ9854
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberM-15488
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: