Provider Demographics
NPI:1497954911
Name:ELYSE R. EISENBERG MD, INC.
Entity Type:Organization
Organization Name:ELYSE R. EISENBERG MD, INC.
Other - Org Name:ELYSE EISENBERG, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELYSE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:EISENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-575-5355
Mailing Address - Street 1:725 FARMERS LN STE 10
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6743
Mailing Address - Country:US
Mailing Address - Phone:707-575-5355
Mailing Address - Fax:866-870-0815
Practice Address - Street 1:725 FARMERS LN STE 10
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6743
Practice Address - Country:US
Practice Address - Phone:707-575-5355
Practice Address - Fax:866-870-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64542207QA0401X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14979554911OtherGROUP'S NPI
00G503680Medicare UPIN