Provider Demographics
NPI:1023143823
Name:SAMUEL J. DAISLEY D.O. INC.
Entity type:Organization
Organization Name:SAMUEL J. DAISLEY D.O. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-293-5555
Mailing Address - Street 1:149 E MAIN ST # 1117
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-9479
Mailing Address - Country:US
Mailing Address - Phone:440-293-5555
Mailing Address - Fax:440-293-6643
Practice Address - Street 1:149 E MAIN ST # 1117
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:OH
Practice Address - Zip Code:44003-9479
Practice Address - Country:US
Practice Address - Phone:440-293-5555
Practice Address - Fax:440-293-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2642975Medicaid
PA1760677OtherHIGHMARK BCBS-OH LOCATION
PA1760704OtherHIGHMARK BCBS-PA LOCATION
PA1760677OtherHIGHMARK BCBS-OH LOCATION
OHSA9264191Medicare ID - Type Unspecified