Healthcare Provider Details

I. General information

NPI: 1477882157
Provider Name (Legal Business Name): UNKNOWN SAMIULLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S FAIRVIEW RD
COLUMBIA MO
65203
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-7600
  • Fax: 573-884-8200
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2014041285
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: