Basic Information
| Provider Information | |||||||||
| NPI: | 1912956277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSEY | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 SUNSET DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376047906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264966 | ||||||||
| FaxNumber: | 4239261823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 SUNSET DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376047906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264966 | ||||||||
| FaxNumber: | 4239261823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 31318 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3840825 | 05 | TN | MEDICAID | Q007699 | 05 | TN | MEDICAID | 1912956277 | 05 | VA | MEDICAID | 300104374 | 01 | TN | RAILROAD MEDICARE | OTHER | 64017064 | 01 | KY | KENTUCKY MEDICAID | OTHER | 89063JF | 01 | NC | NORTH CAROLINA MEDICAID | OTHER | 7222238 | 01 | VA | VIRGINIA MEDICAID | OTHER | 3125936 | 01 | TN | BCBS | OTHER | 100026452 | 01 | TN | PHP TNCARE | OTHER |