Healthcare Provider Details

I. General information

NPI: 1285044313
Provider Name (Legal Business Name): SAMUEL J WALLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE
SPOKANE WA
99204
US

IV. Provider business mailing address

101 W 8TH AVE
SPOKANE WA
99204-2307
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-3181
  • Fax:
Mailing address:
  • Phone: 509-474-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberTL.0005746
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10050008
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD60851653
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: