MEDICARE: MR. SAMSON EBHO OSEBOR RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN2311226	MA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN2311226	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S92075712	OTHER	MA	DRIVER LICENSE

General Provider Information

NPI Number	:	1578298907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMSON EBHO OSEBOR RN

Provider Business Mailing Address
First Line	:	667 MAIN ST APT 29
Second Line	:
City	:	WOBURN
State	:	MA
Zip	:	01801-2377
Country	:	US
Telephone Number	:	781-249-8007
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 BEAR HILL RD STE 104
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-1026
Country	:	US
Telephone Number	:	617-340-3559
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2022
Last Update Date	:	03/11/2024

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