Healthcare Provider Details

I. General information

NPI: 1003898412
Provider Name (Legal Business Name): SAMUEL M. ALLEN II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2005
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S ARCHUSA AVE
QUITMAN MS
39355-2331
US

IV. Provider business mailing address

PO BOX 5208
MERIDIAN MS
39302-5208
US

V. Phone/Fax

Practice location:
  • Phone: 601-776-2123
  • Fax: 601-776-6006
Mailing address:
  • Phone: 601-703-4282
  • Fax: 601-703-4597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number06374
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: