Healthcare Provider Details

I. General information

NPI: 1235144825
Provider Name (Legal Business Name): SAMUEL E CARGILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 COLE ST
ENUMCLAW WA
98022-3504
US

IV. Provider business mailing address

1818 COLE ST
ENUMCLAW WA
98022-3504
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-5760
  • Fax: 360-802-5799
Mailing address:
  • Phone: 360-802-5760
  • Fax: 360-802-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00030972
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier20042177
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerMEDICARE RAILROAD
# 2
Identifier8147761
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier126528
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I
# 4
Identifier100012521
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerMEDICARE RAILROAD
# 5
Identifier126673
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: