Basic Information
| Provider Information | |||||||||
| NPI: | 1235144825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARGILL | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1818 COLE ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608025760 | ||||||||
| FaxNumber: | 3608025799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 COLE ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608025760 | ||||||||
| FaxNumber: | 3608025799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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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 | 208600000X | MD00030972 | WA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 20042177 | 01 | WA | MEDICARE RAILROAD | OTHER | 8147761 | 05 | WA | MEDICAID | 126528 | 01 | WA | STATE L&I | OTHER | 100012521 | 01 | WA | MEDICARE RAILROAD | OTHER | 126673 | 01 | WA | STATE L&I | OTHER |