MEDICARE: SAMANTHA DEMOSS

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	208600000X	Surgery Physician	01095693B	IN
2	390200000X	Student in an Organized Health Care Education/Training Program
3	208600000X	Surgery Physician	125.075907	IL

General Provider Information

NPI Number	:	1629605480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA DEMOSS

Provider Business Mailing Address
First Line	:	1215 HADLEY RD STE 201
Second Line	:
City	:	MOORESVILLE
State	:	IN
Zip	:	46158-2907
Country	:	US
Telephone Number	:	317-834-9618
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 HADLEY RD STE 201
Second Line	:
City	:	MOORESVILLE
State	:	IN
Zip	:	46158-2907
Country	:	US
Telephone Number	:	317-834-9618
Fax Number	:	317-831-9467

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

Provider Enumeration Date	:	03/23/2020
Last Update Date	:	06/16/2025

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Directions to “ SAMANTHA DEMOSS ” Practice Location

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