Basic Information
| Provider Information | |||||||||
| NPI: | 1861447898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAM | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD00047690 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME85330 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7368368 | 01 | AETNA HMO | OTHER | ME85330 | 01 | FL | FLORIDA LICENSE | OTHER | 0249529 | 01 | WA | LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST | OTHER | 264605600 | 05 | FL | MEDICAID | 8943620 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-TRA | OTHER | 8951856 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST | OTHER | 17219 | 01 | BCBS | OTHER | P00428604 | 01 | WA | RR MEDICARE-TRA | OTHER | 8943621 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-UNION AVENUE OPEN MRI | OTHER | 0217647 | 01 | WA | LABOR AND INDUSTRIES-UNION AVENUE OPEN MRI | OTHER | 0217648 | 01 | WA | LABOR AND INDUSTRIES-TRA | OTHER | 2845690 | 01 | AETNA PPO | OTHER |