Healthcare Provider Details

I. General information

NPI: 1982618112
Provider Name (Legal Business Name): SAMUEL C. BIELIGK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501
US

IV. Provider business mailing address

415 6TH STREET ATTN: PHYSICIAN SERVICES
LEWISTON ID
83501-2434
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-7612
  • Fax: 208-746-4802
Mailing address:
  • Phone: 208-750-7462
  • Fax: 208-750-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD57659
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number2008010215
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMC-2661
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: