Healthcare Provider Details

I. General information

NPI: 1053546572
Provider Name (Legal Business Name): LYNN H SAMUEL MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 BLACKWELL ROAD SUITE 101A
WARRENTON VA
20186-2628
US

IV. Provider business mailing address

493 BLACKWELL ROAD SUITE 101A
WARRENTON VA
20186-2628
US

V. Phone/Fax

Practice location:
  • Phone: 540-316-5604
  • Fax: 540-316-5601
Mailing address:
  • Phone: 540-316-5604
  • Fax: 540-316-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number0101044708
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101044708
License Number StateVA

VIII. Authorized Official

Name: LYNN H SAMUEL
Title or Position: OWNER
Credential: MD
Phone: 540-316-5604