MEDICARE: SAMUEL COLERIDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	J2546	TX

General Provider Information

NPI Number	:	1013986058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL COLERIDGE

Provider Business Mailing Address
First Line	:	3500 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2644
Country	:	US
Telephone Number	:	817-735-0170
Fax Number	:	817-735-0111

Provider Business Practice Location Address
First Line	:	2106 N MAIN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-8511
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:	817-740-1318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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Directions to “ SAMUEL COLERIDGE ” Practice Location

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