MEDICARE: MR. SAMUEL FENDERSON

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	246ZC0007X	Surgical Assistant
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1326370545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL FENDERSON

Provider Business Mailing Address
First Line	:	925 MAIN ST # 300-07
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3098
Country	:	US
Telephone Number	:	678-799-2498
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 MAIN ST # 300-07
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3098
Country	:	US
Telephone Number	:	678-799-2498
Fax Number	:

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

Provider Enumeration Date	:	02/12/2010
Last Update Date	:	03/01/2018

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