Healthcare Provider Details

I. General information

NPI: 1861451569
Provider Name (Legal Business Name): SAMAI SUPAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 OKATIE HWY # 170
OKATIE SC
29909-3963
US

IV. Provider business mailing address

154 SPANISH POINT DR
BEAUFORT SC
29902-6126
US

V. Phone/Fax

Practice location:
  • Phone: 843-987-7400
  • Fax: 843-987-5135
Mailing address:
  • Phone: 843-525-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number11283
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: