NPIMap

Individual provider Active NPI

Samuel Lynn Southam, MD

  • Diagnostic Radiology Physician
  • Provo, UT
National Provider Identifier
1104868850
Registry record updated Jun 10, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
2005-0536 Issued in NM
Practice address
1034 N 500 W
Provo, UT 84604-3380
Phone
(801) 357-7850
Fax
(801) 357-7626
NPI assigned
Jun 10, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 12285899-1205 UT
Diagnostic Radiology Physician 2085R0202X 2005-0536 NM Primary

Addresses

Primary practice location

1034 N 500 W
Provo, UT 84604-3380

Mailing address

1034 N 500 W
Provo, UT 84604-3380
Phone (801) 357-7850

Other identifiers 1

IdentifierTypeStateIssuer
76673855MedicaidNM

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NM, UT2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20061104000026 NM Practitioner - Diagnostic Radiology 7416954474 Reassigns benefits to 3 organizations
I20210806002589 UT Practitioner - Diagnostic Radiology 7416954474 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
University of Colorado School of Medicine, Denver, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Ihc Health Services IncGroup PAC ID 1850209420, 3,948 clinicians
Utah Valley Radiology Associates IncGroup PAC ID 1759286990, 35 clinicians

Practice addresses (Care Compare)

1034 N 500
Provo, UT 84604-3380
Phone (801) 357-7850

1055 N 300
Suite 104
Provo, UT 84604-3344
Phone (801) 225-6246

Hospital & facility affiliations

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
2005-0536NMMDDiagnostic Radiology Physician
12285899-1205UTMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Tellica Imaging, LLC CurrentSince Jan 1, 2024 Accepting new patients
Ihc Health Services Inc Current Accepting new patients
Unm Medical Group Inc CurrentSince May 30, 2008 Accepting new patients
Unm Medical Group, Inc. CurrentSince May 30, 2008 Accepting new patients
Ihc Health Services, Inc. CurrentSince Aug 1, 2021 Accepting new patients
Green River Radiology, P.C. Diagnostic Radiology CurrentSince Dec 15, 2021 Accepting new patients
Ihc Health Services Inc CurrentSince Aug 1, 2021 Accepting new patients
University of New Mexico Past Accepting new patients
Riverwoods Urgent Care Center LC PastSince Oct 6, 2003 Accepting new patients

Locations

2211 Lomas Blvd NE
Unm, NM 87106
Phone (505) 272-1111

1034 N 500 W
Provo, UT 84604
Phone (801) 362-4119

1055 N 300 W
Ste 104
Provo, UT 84604
Phone (801) 357-7525

12842 S 3600 W
Ste 100
Riverton, UT 84065
Phone (385) 253-4586

1380 E Medical Center Dr
St George, UT 84790
Phone (435) 251-2992

1380 E Medical Center Dr
#P
St George, UT 84790
Phone (435) 251-2355

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/15493/brand/1/csg/1/fhir/r4

Organizations & group practices 12

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 7

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": "1149897600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623283200000",
    "number": "1104868850",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1034 N 500 W",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846043380",
            "telephone_number": "801-357-7850",
            "fax_number": "801-357-7626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1034 N 500 W",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846043380",
            "telephone_number": "801-357-7850",
            "fax_number": "801-357-7626"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SOUTHAM",
        "first_name": "SAMUEL",
        "middle_name": "LYNN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-10",
        "last_updated": "2021-06-10",
        "certification_date": "2021-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "UT",
            "license": "12285899-1205",
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NM",
            "license": "2005-0536",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "76673855",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Provo, UT

Sources for this page

Verify at the official NPI Registry.