Provider Demographics
NPI:1053380949
Name:SADEGHI, SAM (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:SADEGHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 5A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-224-3500
Practice Address - Fax:423-224-3506
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN40325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100029070Medicaid
VA010213100Medicaid
TN10311I2863Medicare PIN
VA010213100Medicaid
TNP00306165Medicare PIN
TN3335961Medicare PIN