Healthcare Provider Details

I. General information

NPI: 1891778254
Provider Name (Legal Business Name): SAMUEL A BAILEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 STATE ROUTE 162
MARYVILLE IL
62062-8500
US

IV. Provider business mailing address

PO BOX 66971
SAINT LOUIS MO
63166-6971
US

V. Phone/Fax

Practice location:
  • Phone: 800-968-6866
  • Fax:
Mailing address:
  • Phone: 800-968-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85001646
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number085-001646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: