Provider Demographics
NPI:1295419067
Name:ELITE MEDICAL GROUP GP
Entity type:Organization
Organization Name:ELITE MEDICAL GROUP GP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN SLYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-809-2411
Mailing Address - Street 1:901 SAN BERNARDINO RD STE 300
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-7299
Mailing Address - Country:US
Mailing Address - Phone:918-809-2411
Mailing Address - Fax:
Practice Address - Street 1:901 SAN BERNARDINO RD STE 300
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-7299
Practice Address - Country:US
Practice Address - Phone:918-809-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty