Basic Information
| Provider Information | |||||||||
| NPI: | 1265543623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOPPER | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | P, | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 VOLKER HL | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059343795 | ||||||||
| FaxNumber: | 2059758991 | ||||||||
| Practice Location | |||||||||
| Address1: | 1867 CRANE RIDGE DR STE 101B | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013628776 | ||||||||
| FaxNumber: | 6013548786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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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 | 208000000X | 13057 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0019066 | 05 | MS | MEDICAID |