Basic Information
| Provider Information | |||||||||
| NPI: | 1891923900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHARMA | ||||||||
| FirstName: | SAMAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18667 | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410180667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723617 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 268953-1 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 123659 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 54384 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300047449 | 05 | IN | MEDICAID | 7100695660 | 05 | KY | MEDICAID | 0106120 | 05 | OH | MEDICAID |