Provider Demographics
NPI:1396186920
Name:SAMUELSEN, BRIAN T (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:SAMUELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAHEY HOSPITAL & MEDICAL CENTER
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805
Mailing Address - Country:US
Mailing Address - Phone:781-744-8650
Mailing Address - Fax:781-744-5345
Practice Address - Street 1:LAHEY HOSPITAL & MEDICAL CENTER
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805
Practice Address - Country:US
Practice Address - Phone:781-744-8650
Practice Address - Fax:781-744-5345
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58197207X00000X
MA279055207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400172218Medicare PIN