Provider Demographics
NPI:1346299591
Name:MICHELSON, ELYSE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:LYNN
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 FAIRMOUNT AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8518
Mailing Address - Country:US
Mailing Address - Phone:410-526-3041
Mailing Address - Fax:410-584-1890
Practice Address - Street 1:750 MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-2516
Practice Address - Country:US
Practice Address - Phone:410-526-3041
Practice Address - Fax:410-584-1890
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD60680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403260800Medicaid
MDH99042Medicare UPIN
MD403260800Medicaid
154161ZR0ZMedicare PIN
MD157676Medicare PIN
MDP0096830Medicare PIN