Healthcare Provider Details

I. General information

NPI: 1780622761
Provider Name (Legal Business Name): SAMUEL HOUSSAM MARDINI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HOUSSAM EDDIN MARDINI MD

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UK DIVISION OF DIGESTIVE DISEASES 800 ROSE ST, MN654
LEXINGTON KY
40536-0298
US

IV. Provider business mailing address

UK DIVISION OF DIGESTIVE DISEASES 800 ROSE ST, MN654
LEXINGTON KY
40536-0298
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-0079
  • Fax: 859-257-9287
Mailing address:
  • Phone: 859-323-0079
  • Fax: 859-257-9287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24021
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24021
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number37438
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: