Provider Demographics
NPI:1235204405
Name:ELISSA WHITTENBURG MD PA
Entity Type:Organization
Organization Name:ELISSA WHITTENBURG MD PA
Other - Org Name:HILL COUNTY PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITTENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-288-0637
Mailing Address - Street 1:1237 FOX HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-7846
Mailing Address - Country:US
Mailing Address - Phone:513-282-2282
Mailing Address - Fax:513-556-2953
Practice Address - Street 1:1237 FOX HOLLOW DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-7846
Practice Address - Country:US
Practice Address - Phone:513-282-2282
Practice Address - Fax:513-556-2953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX673867261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX673867Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC NBR
H20259Medicare UPIN