Provider Demographics
NPI:1003225061
Name:ELYSE R. EISENBERG, MD, INC.
Entity type:Organization
Organization Name:ELYSE R. EISENBERG, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:707-523-3375
Mailing Address - Street 1:2685 LESLIE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-9607
Mailing Address - Country:US
Mailing Address - Phone:707-477-6617
Mailing Address - Fax:866-415-8441
Practice Address - Street 1:725 FARMERS LN
Practice Address - Street 2:STE 10
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6710
Practice Address - Country:US
Practice Address - Phone:707-523-3375
Practice Address - Fax:866-870-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64542261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center