Basic Information
| Provider Information | |||||||||
| NPI: | 1740366970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | KIRK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1051 LOFTIS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236063069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578739400 | ||||||||
| FaxNumber: | 7578739420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 LOFTIS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236063069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578739400 | ||||||||
| FaxNumber: | 7578739420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207RH0002X | 4301085153 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RH0003X | 0101047339 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1740366970 | 05 | MI | MEDICAID |