1508390782 NPI number — DR. ELYSE MICHELE HUNT-HEINZEN M.D

Table of content: DR. ELYSE MICHELE HUNT-HEINZEN M.D (NPI 1508390782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508390782 NPI number — DR. ELYSE MICHELE HUNT-HEINZEN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUNT-HEINZEN
Provider First Name:
ELYSE
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1508390782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11728 WILSHIRE BLVD APT B103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025-6458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-922-3288
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07960-6136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-971-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2017

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: 207P00000X , with the licence number:  86569 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 03457 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: A173182 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 323980 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112446900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".