Basic Information
| Provider Information | |||||||||
| NPI: | 1629171434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADDOCK | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99213 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854095 | ||||||||
| FaxNumber: | 6828857499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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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 | 207PP0204X | L0812 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006041002 | 05 | TX | MEDICAID | 124211 | 01 | TX | SUPERIOR PIN | OTHER | 2840117 | 01 | TX | CIGNA PIN | OTHER | 006041003 | 05 | TX | MEDICAID | 5297726 | 01 | TX | AETNA PIN | OTHER | 00L42V | 01 | TX | BCBSTX GRP PIN | OTHER | 137283103 | 05 | TX | MEDICAID | 8H8785 | 01 | TX | BCBSTX IND PIN | OTHER | 138456101 | 01 | TX | FIRSTCARE PIN | OTHER | 1746111 | 01 | TX | FIRSTHEALTH PIN | OTHER | 1866576 | 01 | TX | UHC PIN | OTHER | 10032051 | 01 | TX | AMERIGROUP PIN | OTHER | 1669442042 | 01 | GRP NPI NUMBER | OTHER | 137345805 | 05 | TX | MEDICAID |