Healthcare Provider Details

I. General information

NPI: 1023471844
Provider Name (Legal Business Name): SAMUEL VAUGHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE MEDICAL STAFF SERVICES ML 3014
CINCINNATI OH
45229
US

IV. Provider business mailing address

3333 BURNET AVE MEDICAL STAFF SERVICES ML 3014
CINCINNATI OH
45229
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4788
  • Fax: 513-636-4283
Mailing address:
  • Phone: 513-636-4788
  • Fax: 513-636-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.133133
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35.133133
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: