MEDICARE: SAMANTHA HERBERT

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	2255A2300X	Athletic Trainer	RT005859	PA

General Provider Information

NPI Number	:	1508273384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA HERBERT

Provider Business Mailing Address
First Line	:	607 STONELEIGH RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-1646
Country	:	US
Telephone Number	:	410-825-4735
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 STONELEIGH RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-1646
Country	:	US
Telephone Number	:	410-825-4735
Fax Number	:

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

Provider Enumeration Date	:	07/14/2014
Last Update Date	:	07/14/2014

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