Basic Information
| Provider Information | |||||||||
| NPI: | 1164468500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELSENETY | ||||||||
| FirstName: | EVETTE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 27351 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489677750 | ||||||||
| FaxNumber: | 2489677297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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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 | 207ZP0102X | 035480 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 220021537 | 01 | RR MC | OTHER | 382032989 | 01 | TAX ID# | OTHER | 3207140 | 05 | MI | MEDICAID | 5214565 | 05 | MI | MEDICAID | 2206325081 | 01 | BS | OTHER | P00422257 | 01 | RRMC | OTHER |