Basic Information
Provider Information | |||||||||
NPI: | 1780660175 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAMUELS | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | PHILLIP | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1519 | ||||||||
Address2: |   | ||||||||
City: | WHITE SALMON | ||||||||
State: | WA | ||||||||
PostalCode: | 986721519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094932133 | ||||||||
FaxNumber: | 5094939544 | ||||||||
Practice Location | |||||||||
Address1: | 212 SKYLINE DR | ||||||||
Address2: |   | ||||||||
City: | WHITE SALMON | ||||||||
State: | WA | ||||||||
PostalCode: | 98672 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094932133 | ||||||||
FaxNumber: | 5094939544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2005 | ||||||||
LastUpdateDate: | 07/29/2008 | ||||||||
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 | 207Q00000X | 22673 | NE | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD00047504 | WA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD27417 | OR | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8478117 | 05 | WA |   | MEDICAID | FS0236972 | 01 |   | DEA | OTHER | 274532 | 05 | OR |   | MEDICAID | P00462561 | 01 | WA | PTAN | OTHER |