Basic Information
| Provider Information | |||||||||
| NPI: | 1811904881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZACKAI | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259258 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA - GENETICS | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902920 | ||||||||
| FaxNumber: | 2155903298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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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 | 207SC0300X | MD014103E | PA | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Cytogenetic | 207SG0201X | MD014103E | PA | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208000000X | MD014103E | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 25MA07256800 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 207SC0300X | 25MA07256800 | NJ | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Cytogenetic | 207SG0201X | 25MA07256800 | NJ | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 0328600 | 05 | NJ | MEDICAID | 000665287 | 05 | PA | MEDICAID |