Provider Demographics
NPI:1770785289
Name:SAMARA, MARIAH SALLOUM (MD)
Entity type:Individual
Prefix:DR
First Name:MARIAH
Middle Name:SALLOUM
Last Name:SAMARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 HILLSIDE AVE
Mailing Address - Street 2:BOSTON ENT ASSOCIATES
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494
Mailing Address - Country:US
Mailing Address - Phone:781-444-4722
Mailing Address - Fax:781-444-4721
Practice Address - Street 1:560 HILLSIDE AVE
Practice Address - Street 2:BOSTON ENT ASSOCIATES
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494
Practice Address - Country:US
Practice Address - Phone:781-444-4722
Practice Address - Fax:781-444-4721
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35093456207Y00000X
MA258915207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2991295Medicaid
OH2991295Medicaid