Basic Information
| Provider Information | |||||||||
| NPI: | 1104868850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHAM | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577850 | ||||||||
| FaxNumber: | 8013577626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577850 | ||||||||
| FaxNumber: | 8013577626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 12285899-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2005-0536 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 76673855 | 05 | NM | MEDICAID |