Healthcare Provider Details

I. General information

NPI: 1144389586
Provider Name (Legal Business Name): ELENA M LLIVINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 STONEGATE TRL SUITE 112
BIRMINGHAM AL
35242-2246
US

IV. Provider business mailing address

2000 STONEGATE TRL SUITE 112
BIRMINGHAM AL
35242-2246
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-9876
  • Fax: 205-977-9876
Mailing address:
  • Phone: 205-977-9876
  • Fax: 205-977-9876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number062913
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number29784
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: