MEDICARE: FANIA SAMUELS 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	207RC0000X	Cardiovascular Disease Physician	MD042597E	PA
2	207RC0001X	Clinical Cardiac Electrophysiology Physician	MD042597E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0833050000	OTHER	PA	KEYSTONE IBC
2	30133381	OTHER	PA	KEYSTONE FIRST
3	8692853	OTHER	PA	AETNA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	806944	OTHER	PA	HIGHMARK BLUE SHIELD
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255305017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANIA SAMUELS MD

Provider Business Mailing Address
First Line	:	PO BOX 8500-6335
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19178-0001
Country	:	US
Telephone Number	:	215-671-3920
Fax Number	:	215-671-3939

Provider Business Practice Location Address
First Line	:	10160 BUSTLETON AVE
Second Line	:	SUITE C
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3749
Country	:	US
Telephone Number	:	215-671-3920
Fax Number	:	215-671-3939

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

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	01/17/2014

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Directions to “ FANIA SAMUELS MD” Practice Location

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