1164468500 NPI number — EVETTE N ELSENETY MD

Table of content: EVETTE N ELSENETY MD (NPI 1164468500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164468500 NPI number — EVETTE N ELSENETY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELSENETY
Provider First Name:
EVETTE
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164468500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 SOUTHWYCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
419-866-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27351 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-3487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-967-7750
Provider Business Practice Location Address Fax Number:
248-967-7297
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  035480 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 220021537 . This is a "RR MC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 382032989 . This is a "TAX ID#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3207140 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5214565 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2206325081 . This is a "BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00422257 . This is a "RRMC" identifier . This identifiers is of the category "OTHER".




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