Healthcare Provider Details

I. General information

NPI: 1659506624
Provider Name (Legal Business Name): BISHOY T SAMUEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15251 PLEASANT VALLEY RD
CENTER CITY MN
55012-9640
US

IV. Provider business mailing address

15251 PLEASANT VALLEY RD
CENTER CITY MN
55012-9640
US

V. Phone/Fax

Practice location:
  • Phone: 877-793-5205
  • Fax:
Mailing address:
  • Phone: 877-793-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number0101274943
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34453
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA148818
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberT-3860
License Number StateMS
# 5
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number76576
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: