Basic Information
| Provider Information | |||||||||
| NPI: | 1881836476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | SAMIR | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 PAWNEE CT | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197021911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845651510 | ||||||||
| FaxNumber: | 4845651513 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 PAWNEE CT | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023799718 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2009 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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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 | 207R00000X | LP01023 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD439895 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | MD439895 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 232359401 | 01 | PA | MAIN LINE HEALTHCARE TAX ID | OTHER |