Basic Information
| Provider Information | |||||||||
| NPI: | 1316981780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELNESR | ||||||||
| FirstName: | MOMEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 64 BARTON ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047692610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077609090 | ||||||||
| FaxNumber: | 2074924889 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 BARTON ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047692610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077609090 | ||||||||
| FaxNumber: | 2074924889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 158266 | MA | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | 158266 | MA | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0800X | 13957 | ME | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | 13957 | ME | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 9150281047 | 01 | ME | MEDICAL EDUCATION NUMBER | OTHER | 13957 | 01 | ME | LICENSE | OTHER | 158266 | 01 | MA | PHYSICIAN LICENSE | OTHER |