Provider Demographics
NPI:1487637278
Name:PASS, ELAINE ELYSHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:ELYSHIA
Last Name:PASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:101 W 12TH ST
Mailing Address - Street 2:12W
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8142
Mailing Address - Country:US
Mailing Address - Phone:718-599-0477
Mailing Address - Fax:718-599-8677
Practice Address - Street 1:820 BROADWAY
Practice Address - Street 2:FLOOR 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-7305
Practice Address - Country:US
Practice Address - Phone:718-599-0477
Practice Address - Fax:718-599-8677
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY097408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00164049Medicaid
NY00164049Medicaid
NY539651Medicare ID - Type Unspecified