MEDICARE: ELISIVE QUALITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1275782245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELISIVE QUALITY

Provider Business Mailing Address
First Line	:	925B PEACHTREE ST NE # 131
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-3918
Country	:	US
Telephone Number	:	404-580-1041
Fax Number	:

Provider Business Practice Location Address
First Line	:	925B PEACHTREE ST NE # 131
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-3918
Country	:	US
Telephone Number	:	404-580-1041
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. ISMAEL SUARES MEDINA
Credential	:
Telephone Number	:	404-580-1041

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	10/16/2008

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Directions to “ELISIVE QUALITY ” Practice Location

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