Healthcare Provider Details

I. General information

NPI: 1902863954
Provider Name (Legal Business Name): SAMUEL R DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 6TH AVE
MONTGOMERY WV
25136-2117
US

IV. Provider business mailing address

400 6TH AVE
MONTGOMERY WV
25136-2117
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-5151
  • Fax: 304-442-1347
Mailing address:
  • Phone: 304-442-5151
  • Fax: 304-442-1347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number13914
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: