Provider Demographics
NPI:1932134533
Name:ELENITSAS, ROSALIE (MD)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:
Last Name:ELENITSAS
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 1:3400 SPRUCE STREET
Mailing Address - Street 2:2 MALONEY BLDG
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2737
Mailing Address - Fax:215-349-8339
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:2 MALONEY BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2737
Practice Address - Fax:215-349-8339
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037866E207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001637400001Medicaid
PA001637400001Medicaid
PA438566Medicare PIN