Provider Demographics
NPI:1043542459
Name:ELIEZER MONGE, M.D., P.C.
Entity Type:Organization
Organization Name:ELIEZER MONGE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-474-5215
Mailing Address - Street 1:23607 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3109
Mailing Address - Country:US
Mailing Address - Phone:248-474-5215
Mailing Address - Fax:248-474-7260
Practice Address - Street 1:23607 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3109
Practice Address - Country:US
Practice Address - Phone:248-474-5215
Practice Address - Fax:248-474-7260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027308207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1047315Medicaid
MIB46808Medicare UPIN
MI2712001Medicare PIN