Provider Demographics
NPI:1992813257
Name:SAMUEL, ELAINE SUSAN (MD)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:SUSAN
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:SPIKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:935 HIGHLAND BLVD 2200
Mailing Address - Street 2:BH FAMILY MEDICINE
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6915
Mailing Address - Country:US
Mailing Address - Phone:406-414-5700
Mailing Address - Fax:
Practice Address - Street 1:935 HIGHLAND BLVD STE 2200
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6915
Practice Address - Country:US
Practice Address - Phone:406-414-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1992813257Medicaid