Basic Information
| Provider Information | |||||||||
| NPI: | 1053354043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLINGSWORTH | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N MERIDIAN ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179624941 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 N SENATE BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179625581 | ||||||||
| FaxNumber: | 3179625859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/06/2010 | ||||||||
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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 | 207R00000X | 01032077 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100236860 | 05 | IN | MEDICAID |