Provider Demographics
NPI:1861661092
Name:SUN, MARYELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:SUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 LEE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5912
Mailing Address - Country:US
Mailing Address - Phone:617-487-5215
Mailing Address - Fax:
Practice Address - Street 1:BETH ISRAEL DEACONESS MEDICAL CENTER
Practice Address - Street 2:330 BROOKLINE AVENUE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-754-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2344872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology