1710334818 NPI number — MISS ELISE SIMONE YERELIAN MD

Table of content: MISS ELISE SIMONE YERELIAN MD (NPI 1710334818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710334818 NPI number — MISS ELISE SIMONE YERELIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YERELIAN
Provider First Name:
ELISE
Provider Middle Name:
SIMONE
Provider Name Prefix Text:
MISS
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:
1710334818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-953-0104
Provider Business Mailing Address Fax Number:
303-765-6670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2490 W 26TH AVE STE 120A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80211-5317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-925-4580
Provider Business Practice Location Address Fax Number:
303-925-4581
Provider Enumeration Date:
05/18/2016

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: 207Q00000X , with the licence number:  DR.0061182 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000137370 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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