MEDICARE: DR. MARY SUSAN ELACQUA M.D.

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	207VG0400X	Gynecology Physician	149514	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	160007874	OTHER	NY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	141655014	OTHER	NY	EMPIRE PLAN
3	16152	OTHER	NY	MVP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	113801	OTHER	NY	WELLCARE
6	13801	OTHER	NY	GHIHMO
7	10000563	OTHER	NY	CDPHP
8	52E361	OTHER	NY	BLUE CROSS
9	000416081001	OTHER	NY	BLUE SHIELD
10	0015055	OTHER	NY	GHI
11	141655014	OTHER	NY	UNITED HEALTHCARE
12	0005361476	OTHER	NY	AETNA
13	040426006334	OTHER	NY	FIDELIS
14	00020780401	OTHER	NY	UNIVERA

General Provider Information

NPI Number	:	1316904105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY SUSAN ELACQUA M.D.

Provider Business Mailing Address
First Line	:	711 TROY SCHENECTADY RD
Second Line	:	SUITE 203
City	:	LATHAM
State	:	NY
Zip	:	12110-2442
Country	:	US
Telephone Number	:	518-782-3700
Fax Number	:	518-782-3799

Provider Business Practice Location Address
First Line	:	101 JORDAN RD
Second Line	:	SUITE 200
City	:	TROY
State	:	NY
Zip	:	12180-8343
Country	:	US
Telephone Number	:	518-274-0476
Fax Number	:	518-274-0497

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	10/06/2014

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