1184844771 NPI number — ELY D PELTA MD PA

Table of content: (NPI 1184844771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184844771 NPI number — ELY D PELTA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELY D PELTA MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CORAL SPRINGS PHOBIA CENTER
Provider Other Organization Name Type Code:
3
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:
1184844771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5551 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33067-4651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-345-8733
Provider Business Mailing Address Fax Number:
954-345-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5551 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33067-4651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-345-8733
Provider Business Practice Location Address Fax Number:
954-345-8233
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PELTA
Authorized Official First Name:
ELY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-345-8733

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CM3126 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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