Healthcare Provider Details

I. General information

NPI: 1851694517
Provider Name (Legal Business Name): PRIYAN SAMARAKOON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH MAIN STREET
CLIO SC
29525
US

IV. Provider business mailing address

11560 FAIRWAY DR
LAURINBURG NC
28352-7958
US

V. Phone/Fax

Practice location:
  • Phone: 843-586-2292
  • Fax: 843-306-4622
Mailing address:
  • Phone: 910-534-4434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberNC - 2009-01120
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberSC - MD 28542
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberNC - 2009-01120
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberSC - MD 28542
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberNC - 2009-01120
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberSC - MD 28542
License Number StateSC

VIII. Authorized Official

Name: PRIYAN SAMARAKOON
Title or Position: MEMBER
Credential: MD
Phone: 910-534-4434