Basic Information
| Provider Information | |||||||||
| NPI: | 1114028743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORRELLI | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BORRELLI | ||||||||
| OtherFirstName: | SALVATORE | ||||||||
| OtherMiddleName: | JOSEPH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25651 COUNTY ROAD 20 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465172310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745221201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25651 COUNTY ROAD 20 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465172310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745221201 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01035824 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000091945 | 01 | IN | ANTHEM | OTHER | 080134326 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 100113550 | 05 | IN | MEDICAID |