MEDICARE: SAMAI SUPAN 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	207QA0505X	Adult Medicine Physician	11283	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11283	OTHER	SC	STATE LICENSE

General Provider Information

NPI Number	:	1861451569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMAI SUPAN M.D.

Provider Business Mailing Address
First Line	:	154 SPANISH POINT DR
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29902-6126
Country	:	US
Telephone Number	:	843-525-6569
Fax Number	:

Provider Business Practice Location Address
First Line	:	719 OKATIE HWY # 170
Second Line	:
City	:	OKATIE
State	:	SC
Zip	:	29909-3963
Country	:	US
Telephone Number	:	843-987-7400
Fax Number	:	843-987-5135

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

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	03/10/2020

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