MEDICARE: SAMUEL ORNELAS 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	9408359	KS
2	2085R0202X	Diagnostic Radiology Physician	R6862	TX
3	2085R0202X	Diagnostic Radiology Physician	0438267	KS

General Provider Information

NPI Number	:	1467866178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL ORNELAS MD

Provider Business Mailing Address
First Line	:	1133 COLLEGE AVE STE C143
Second Line	:
City	:	MANHATTAN
State	:	KS
Zip	:	66502-2751
Country	:	US
Telephone Number	:	785-539-7641
Fax Number	:	785-537-7620

Provider Business Practice Location Address
First Line	:	1133 COLLEGE AVE STE C143
Second Line	:
City	:	MANHATTAN
State	:	KS
Zip	:	66502-2751
Country	:	US
Telephone Number	:	785-539-7641
Fax Number	:	785-537-7620

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

Provider Enumeration Date	:	06/20/2014
Last Update Date	:	10/20/2020

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