Healthcare Provider Details

I. General information

NPI: 1942731955
Provider Name (Legal Business Name): SAMUEL CLINTON WALLING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 KRESGE WAY STE 200
LOUISVILLE KY
40207-4640
US

IV. Provider business mailing address

800 ROSE ST # C-246
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-1995
  • Fax: 502-928-3972
Mailing address:
  • Phone: 859-323-6162
  • Fax: 859-257-8934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number56880
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number56880
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: