Provider Demographics
NPI:1770500431
Name:ELLIAS, MAZIN (MD)
Entity Type:Individual
Prefix:
First Name:MAZIN
Middle Name:
Last Name:ELLIAS
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 1:4131 W LOOMIS RD
Mailing Address - Street 2:STE 300
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2057
Mailing Address - Country:US
Mailing Address - Phone:414-325-7246
Mailing Address - Fax:414-325-3770
Practice Address - Street 1:4131 W LOOMIS RD
Practice Address - Street 2:STE 300
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2057
Practice Address - Country:US
Practice Address - Phone:414-325-7246
Practice Address - Fax:414-325-3770
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40486020207L00000X
WI40486-020207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391330887OtherASSOCIATES FOR HEALTHCARE
WI391330887OtherHEALTH EOS
WI32492200OtherMANAGED HEALTH CARE
WIP00267689OtherMEDICARE RAILROAD
WI68959OtherSECURITY HEALTH PLAN
WI32492200Medicaid
WI68959OtherSECURITY HEALTH MEDICAID
WI002339110OtherMEDICARE - HUMANA GOLD
WIELLIASOtherWPS
WI32492200Medicaid
WIELLIASOtherWPS
WI68959OtherSECURITY HEALTH PLAN