Provider Demographics
NPI:1114028743
Name:BORRELLI, SAM JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:JOSEPH
Last Name:BORRELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SALVATORE
Other - Middle Name:JOSEPH
Other - Last Name:BORRELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:25651 COUNTY ROAD 20
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-2310
Mailing Address - Country:US
Mailing Address - Phone:574-522-1201
Mailing Address - Fax:
Practice Address - Street 1:25651 COUNTY ROAD 20
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2310
Practice Address - Country:US
Practice Address - Phone:574-522-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000091945OtherANTHEM
IN080134326OtherRAIL ROAD MEDICARE
IN100113550Medicaid
IN100113550Medicaid
IN227950013Medicare PIN