Basic Information
| Provider Information | |||||||||
| NPI: | 1649286493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAHL | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ISAAC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102954400 | ||||||||
| FaxNumber: | 9102952810 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102954400 | ||||||||
| FaxNumber: | 9102952810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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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 | 2085R0202X | 2006-01411 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 2006-01411 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 14263 | 01 | NC | BCBS NC | OTHER | 5904644 | 05 | NC | MEDICAID |