Provider Demographics
NPI:1033597828
Name:ELITE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:ELITE INTERNAL MEDICINE
Other - Org Name:PROSPECT INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:YUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-713-1332
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-0319
Mailing Address - Country:US
Mailing Address - Phone:502-713-1332
Mailing Address - Fax:502-713-1218
Practice Address - Street 1:9537 US HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9301
Practice Address - Country:US
Practice Address - Phone:502-713-1332
Practice Address - Fax:502-713-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50091760OtherPASSPORT HEALTH PLAN
KY50091760OtherPASSPORT HEALTH PLAN