Basic Information
| Provider Information | |||||||||
| NPI: | 1841251949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTIAN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16568 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322456568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044722300 | ||||||||
| FaxNumber: | 9044722330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 13TH AVENUE, SOUTH | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042471456 | ||||||||
| FaxNumber: | 9042472281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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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 | 207V00000X | ME25672 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 041409300 | 05 | FL | MEDICAID |