Provider Demographics
NPI:1790487437
Name:ELEY, SAMUEL THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:THEODORE
Last Name:ELEY
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 1:15 PARKMAN STREET
Mailing Address - Street 2:WACC 625
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-8135
Mailing Address - Fax:617-724-8010
Practice Address - Street 1:15 PARKMAN STREET
Practice Address - Street 2:WACC 625
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-8135
Practice Address - Fax:617-724-8010
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPENDING390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program