Healthcare Provider Details

I. General information

NPI: 1770069353
Provider Name (Legal Business Name): SAMUEL ROBERT BRITTINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E. CARROLL ST 3RD FLOOR, WEST TOWER
SALISBURY MD
21801
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-546-1353
  • Fax:
Mailing address:
  • Phone: 800-749-5191
  • Fax: 410-630-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006868
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: