Basic Information
| Provider Information | |||||||||
| NPI: | 1871867911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE HEALTHCARE MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154721488 | ||||||||
| FaxNumber: | 3154761792 | ||||||||
| Practice Location | |||||||||
| Address1: | 8100 OSWEGO RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130901654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157014024 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2012 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | RAPHAEL | ||||||||
| AuthorizedOfficialFirstName: | IRVING | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3157014000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 03397082 | 05 | NY | MEDICAID |