Basic Information
| Provider Information | |||||||||
| NPI: | 1780622761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARDINI | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | HOUSSAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARDINI | ||||||||
| OtherFirstName: | HOUSSAM | ||||||||
| OtherMiddleName: | EDDIN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | UK DIVISION OF DIGESTIVE DISEASES | ||||||||
| Address2: | 800 ROSE ST, MN654 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593230079 | ||||||||
| FaxNumber: | 8592579287 | ||||||||
| Practice Location | |||||||||
| Address1: | UK DIVISION OF DIGESTIVE DISEASES | ||||||||
| Address2: | 800 ROSE ST, MN654 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593230079 | ||||||||
| FaxNumber: | 8592579287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 24021 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | 24021 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 37438 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.