Provider Demographics
NPI:1841223633
Name:ELIAS, SALLY SAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:SAMIR
Last Name:ELIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4488
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:11715 ORPINGTON STREET, SUITE A
Practice Address - Street 2:TLC PEDIATRICS AND ADOLESCENT MEDICINE IN ASSOC WITH NE
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4600
Practice Address - Country:US
Practice Address - Phone:407-380-9115
Practice Address - Fax:407-380-9189
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME92588208000000X
FLME92584208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004130500Medicaid
FL28634OtherBCBS
FL2540464OtherUNITED HEALTHCARE
FL8894941OtherCIGNA HEALTHCARE
FL18160OtherFHHS
FL7428721OtherAETNA HEALTHCARE
FL28634ZMedicaid
FL7428721OtherAETNA HEALTHCARE