Basic Information
| Provider Information | |||||||||
| NPI: | 1144715384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELMI | ||||||||
| FirstName: | MARYAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8431 FREDERICKSBURG ROAD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104509000 | ||||||||
| FaxNumber: | 2104504621 | ||||||||
| Practice Location | |||||||||
| Address1: | 7979 WURZBACH | ||||||||
| Address2: | 6TH FLOOR, ZELLER BLDG | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104505990 | ||||||||
| FaxNumber: | 2104501747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | R6389 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | R6389 | TX | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 387011501 | 05 | TX | MEDICAID | 387011502 | 01 | TX | CSHCN | OTHER |