Provider Demographics
NPI:1174540173
Name:BORSELLINO, SAMUEL R (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:BORSELLINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 KOLBE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1652
Mailing Address - Country:US
Mailing Address - Phone:440-930-6015
Mailing Address - Fax:440-930-6094
Practice Address - Street 1:3600 KOLBE RD STE 100
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1652
Practice Address - Country:US
Practice Address - Phone:440-930-6015
Practice Address - Fax:440-930-6094
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-024312084N0400X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2710687Medicaid