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General NPI Number Information
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NPI Number | 1518928167
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Entity Type | Individual
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Provider Name | SAMUEL MICHAEL THEAGENE MD
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Gender | Male
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Dates
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Enumeration Date | 03/31/2006
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Last Update Date | 03/04/2024
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Provider Practice Location Address
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Address Line | 22422 MERRICK BLVD
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City | LAURELTON
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State | NY
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Zip | 11413-2023
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Country | US
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Telephone | 347-270-8353
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Fax | 347-826-1917
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Provider Business Mailing Address
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Address Line | 22422 MERRICK BLVD
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City | LAURELTON
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State | NY
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Zip | 11413-2023
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Country | US
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Telephone | 347-270-8353
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Fax | 347-826-1917
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 194218
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 194218
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License Number State | NY
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