Provider Demographics
NPI:1376614750
Name:ERLICH, ELYSE R (MD)
Entity Type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:R
Last Name:ERLICH
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 1:260 LONG RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1627
Mailing Address - Country:US
Mailing Address - Phone:475-619-6035
Mailing Address - Fax:203-316-0288
Practice Address - Street 1:260 LONG RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1627
Practice Address - Country:US
Practice Address - Phone:475-619-6035
Practice Address - Fax:203-316-0288
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191306207R00000X
CT55333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT55333OtherCT LICENSE
NYF89811Medicare UPIN