NPIMap

Individual provider Active NPI

Lisa Michelle Samuelson, MD

  • Emergency Medicine Physician
  • Charleston, SC
National Provider Identifier
1043771405
Registry record updated Jun 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
MMD.89586 Issued in SC
Practice address
171 Ashley Ave
Charleston, SC 29425-8908
Phone
(843) 792-1414
NPI assigned
Mar 28, 2019
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 20, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X 70510 CT
Emergency Medicine Physician 207P00000X MMD.89586 SC Primary

Addresses

Primary practice location

171 Ashley Ave
Charleston, SC 29425-8908

Mailing address

171 Ashley Ave
Charleston, SC 29425-8908

Other names 1

  • Lisa Michelle Petruncio Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20240103002895 SC Practitioner - Emergency Medicine 7810220571 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Medical University of South Carolina College of Medicine, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

171 Ashley Ave
Charleston, SC 29425-8908
Phone (843) 792-1414

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
79.02 of 100Reported as group
Quality
62.41
Promoting interoperability
99
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MMD.89586SCMDEmergency Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
University Medical Associates CurrentSince Jul 13, 2023 Accepting new patients
Hartford Pathology Associates, P.C. Current Accepting new patients
The Hospital of Central Connecticut at New Britain General and Bradley CurrentSince Jul 1, 2022 Accepting new patients
The Hospital of Central Connecticut at New Britain General and Bradley Current Accepting new patients
The Hospital of Central Connecticut at New Britain General and Bradley CurrentSince Jul 1, 2022 Accepting new patients
University Medical Associates of the Medical University of South Carol Current Accepting new patients
University Medical Associates of the Medical University of South Carol CurrentSince Jul 13, 2023 Accepting new patients

Locations

100 Grand St
New Britain, CT 06052
Phone (860) 224-5011

1290 Silas Deane Hwy
Wethersfield, CT 06109
Phone (860) 972-6977

171 Ashley Ave
Charleston, SC 29425
Phone (843) 792-2123

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1553731200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1718841600000",
    "number": "1043771405",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "171 ASHLEY AVE",
            "city": "CHARLESTON",
            "state": "SC",
            "postal_code": "294258908"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "171 ASHLEY AVE",
            "city": "CHARLESTON",
            "state": "SC",
            "postal_code": "294258908",
            "telephone_number": "843-792-1414"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SAMUELSON",
        "first_name": "LISA",
        "middle_name": "MICHELLE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-03-28",
        "last_updated": "2024-06-20",
        "certification_date": "2024-06-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "CT",
            "license": "70510",
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "SC",
            "license": "MMD.89586",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LISA",
            "last_name": "PETRUNCIO",
            "middle_name": "MICHELLE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Charleston, SC

Sources for this page

Verify at the official NPI Registry.