1023022662 NPI number — MS. ELLEN E SAMPSON NP

Table of content: MS. ELLEN E SAMPSON NP (NPI 1023022662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023022662 NPI number — MS. ELLEN E SAMPSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPSON
Provider First Name:
ELLEN
Provider Middle Name:
E
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023022662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 PRESTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ROXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02132-2815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-325-1054
Provider Business Mailing Address Fax Number:
617-479-4555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1261 FURNACE BROOK PKWY
Provider Second Line Business Practice Location Address:
SUITE 31
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-479-4545
Provider Business Practice Location Address Fax Number:
617-479-4555
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  172153 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0708020 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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