Healthcare Provider Details

I. General information

NPI: 1497578702
Provider Name (Legal Business Name): MR. SAM J. GELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 09/08/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CAMPANELLA WAY
CHESTNUT HILL MA
02467
US

IV. Provider business mailing address

46 RAYMOND DR
CUMBERLAND RI
02864-4720
US

V. Phone/Fax

Practice location:
  • Phone: 617-552-9112
  • Fax:
Mailing address:
  • Phone: 401-787-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATL22108
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: