Provider Demographics
NPI:1164404471
Name:ELNICK, MARY JO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JO
Last Name:ELNICK
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Gender:F
Credentials:MD
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Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:STE 304
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-569-4366
Mailing Address - Fax:248-569-4614
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:STE 304
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-569-4366
Practice Address - Fax:248-569-4614
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MIME404005207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10275190Medicaid
MI10275190Medicaid
MIOF37271003Medicare ID - Type Unspecified