Healthcare Provider Details

I. General information

NPI: 1639731177
Provider Name (Legal Business Name): SAMUEL WARN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2019
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 RESEARCH PARK BLVD
MADISON WI
53719-1176
US

IV. Provider business mailing address

6001 RESEARCH PARK BLVD
MADISON WI
53719-1176
US

V. Phone/Fax

Practice location:
  • Phone: 608-232-3171
  • Fax:
Mailing address:
  • Phone: 608-232-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number65609
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number84162-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8526
License Number StateNE

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: