Provider Demographics
NPI:1750415576
Name:ELIZABETH R ELINE DPM PA
Entity type:Organization
Organization Name:ELIZABETH R ELINE DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:830-372-3668
Mailing Address - Street 1:1064 E IRELAND ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-4849
Mailing Address - Country:US
Mailing Address - Phone:830-372-3668
Mailing Address - Fax:830-379-1604
Practice Address - Street 1:1064 E IRELAND ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4849
Practice Address - Country:US
Practice Address - Phone:830-372-3668
Practice Address - Fax:830-379-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1237213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0849044-01Medicaid
TX480018841OtherRAILROAD MEDICARE
TX80X040OtherBLUE CROSS BLUE SHIELD
TXU08117Medicare UPIN
00R79RMedicare ID - Type Unspecified