Basic Information
| Provider Information | |||||||||
| NPI: | 1306835145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELOVIC | ||||||||
| FirstName: | ELIE | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2154565926 | ||||||||
| Practice Location | |||||||||
| Address1: | 1495 MILL ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759823500 | ||||||||
| FaxNumber: | 7759823665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 16186 | NV | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 25MA05971300 | NJ | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | MD032799E | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 7277536-1205 | UT | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 35134992 | OH | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 10655580 | 01 | CAQH | OTHER | 1306835145 | 05 | NV | MEDICAID |