MEDICARE: SAMUEL WELLINGTON COPELAND MD

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	207R00000X	Internal Medicine Physician	Q9796	TX
2	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	Q9796	TX
3	390200000X	Student in an Organized Health Care Education/Training Program
4	207RP1001X	Pulmonary Disease Physician	Q9796	TX

General Provider Information

NPI Number	:	1063774198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL WELLINGTON COPELAND MD

Provider Business Mailing Address
First Line	:	2705 HOSPITAL DR STE 402
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-5777
Country	:	US
Telephone Number	:	361-574-1780
Fax Number	:	361-574-1785

Provider Business Practice Location Address
First Line	:	2705 HOSPITAL DR STE 402
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-5777
Country	:	US
Telephone Number	:	361-574-1780
Fax Number	:	361-574-1785

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

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	07/11/2019

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