Individual
DR. SAMUEL MICHAEL THEAGENE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
22422 MERRICK BLVD, LAURELTON, NY 11413-2023
(347) 270-8353
(347) 826-1917
Mailing address
22422 MERRICK BLVD, LAURELTON, NY 11413-2023
(347) 270-8353
(347) 826-1917
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
194218
NY
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
194218
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
135761803
—
TX
01
—
G400043923
PTAN
NY
Enumeration date
03/31/2006
Last updated
03/04/2024
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