Provider Demographics
NPI:1346241189
Name:ELISCO, ALVIN B (MD)
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:B
Last Name:ELISCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:FMC HOSPITALISTS
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-214-2920
Practice Address - Fax:928-214-2925
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14146207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAW9356OtherHEALTHNET
AZ3874719OtherAETNA
AZP01109107OtherRAILROAD MEDICARE
AZ248741Medicaid
AZAZ0780670OtherBCBS
AZZ141955Medicare PIN
AZAW9356OtherHEALTHNET