1770500431 NPI number — MAZIN ELLIAS M.D.

Table of content: MAZIN ELLIAS M.D. (NPI 1770500431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770500431 NPI number — MAZIN ELLIAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIAS
Provider First Name:
MAZIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1770500431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4131 W LOOMIS RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-325-7246
Provider Business Mailing Address Fax Number:
414-325-3770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4131 W LOOMIS RD
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-2057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-325-7246
Provider Business Practice Location Address Fax Number:
414-325-3770
Provider Enumeration Date:
07/17/2006

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: 207L00000X , with the licence number:  40486020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 40486-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 391330887 . This is a "ASSOCIATES FOR HEALTHCARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391330887 . This is a "HEALTH EOS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32492200 . This is a "MANAGED HEALTH CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: P00267689 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 68959 . This is a "SECURITY HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32492200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 68959 . This is a "SECURITY HEALTH MEDICAID" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 002339110 . This is a "MEDICARE - HUMANA GOLD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: ELLIAS . This is a "WPS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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