MEDICARE: DR. JESSE SAMUELS M.D.

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	207Q00000X	Family Medicine Physician	014481	CT

General Provider Information

NPI Number	:	1588661813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE SAMUELS M.D.

Provider Business Mailing Address
First Line	:	25 CASCADE RD
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2006
Country	:	US
Telephone Number	:	860-636-9574
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 CASCADE RD
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2006
Country	:	US
Telephone Number	:	860-636-9574
Fax Number	:

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	07/08/2007

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