Healthcare Provider Details

I. General information

NPI: 1730267980
Provider Name (Legal Business Name): CATHRYN L SAMPLES M.D., MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE LO-306, ADOLESCENT MEDICINE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE LO-306
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7181
  • Fax: 617-730-0195
Mailing address:
  • Phone: 617-355-2735
  • Fax: 617-730-0195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42863
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number42863
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: