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General NPI Number Information
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NPI Number | 1598735466
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Entity Type | Organization
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Legal Business Name | SHANE T SAMPSON MD INC
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Dates
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Enumeration Date | 01/24/2006
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Last Update Date | 04/02/2012
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Provider Practice Location Address
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Address Line | 122 MARTZ ST
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City | GREENVILLE
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State | OH
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Zip | 45331-1052
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Country | US
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Telephone | 937-459-5057
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Fax | 937-459-5285
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Provider Business Mailing Address
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Address Line | 122 MARTZ ST PO BOX 960
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City | GREENVILLE
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State | OH
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Zip | 45331-1052
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Country | US
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Telephone | 937-459-5057
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Fax | 937-459-5285
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Authorized Official
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Title or Position | PRESIDENT CEO
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Name | SHANE TIMOTHY SAMPSON
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Credential | MD
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Telephone | 937-459-5057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01038529
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35063468
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License Number State | OH
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