Basic Information
| Provider Information | |||||||||
| NPI: | 1043266380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | PREM | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 W 119TH ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662093721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139060833 | ||||||||
| FaxNumber: | 8165235747 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 W 119TH ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662093721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139060833 | ||||||||
| FaxNumber: | 8165235747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 01/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 29521 | KS | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100416510B | 05 | KS | MEDICAID | 205761604 | 05 | MO | MEDICAID | 100416510C | 05 | KS | MEDICAID |