Basic Information
| Provider Information | |||||||||
| NPI: | 1376571091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMUELSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12639 OLD TESSON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148490311 | ||||||||
| FaxNumber: | 3148494423 | ||||||||
| Practice Location | |||||||||
| Address1: | 10701 NALL AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133815225 | ||||||||
| FaxNumber: | 9139010186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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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 | 207X00000X | 0425054 | KS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 20871010 | 01 | BCBS KC | OTHER | 20871010 | 01 | BCBS OTHER | OTHER | 4675214 | 01 | AETNA | OTHER | P01049730 | 01 | RAILROAD MEDICARE | OTHER |