Healthcare Provider Details

I. General information

NPI: 1609972082
Provider Name (Legal Business Name): MERVYN J. SAMUEL, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 CLEVELAND AVE. SUITE 100
COLUMBUS OH
43231
US

IV. Provider business mailing address

200 BRADENTON AVENUE
DUBLIN OH
43017
US

V. Phone/Fax

Practice location:
  • Phone: 614-882-4343
  • Fax:
Mailing address:
  • Phone: 614-793-1982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35-03-5794-S
License Number StateOH

VIII. Authorized Official

Name: MERVYN J. SAMUEL
Title or Position: OWNER
Credential: M.D.
Phone: 614-882-4343