Healthcare Provider Details

I. General information

NPI: 1396985636
Provider Name (Legal Business Name): AYAZ M. SAMADANI, MD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 CORPORATE DR SUITE H
BEAVER DAM WI
53916-3123
US

IV. Provider business mailing address

215 CORPORATE DR SUITE H
BEAVER DAM WI
53916-3123
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-7731
  • Fax:
Mailing address:
  • Phone: 920-887-7731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: AYAZ M SAMADANI
Title or Position: OWNER
Credential: MD
Phone: 920-887-7731