Healthcare Provider Details

I. General information

NPI: 1043902885
Provider Name (Legal Business Name): ELITE MULTI SPECIALTY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15255 N 40TH ST
PHOENIX AZ
85032-4624
US

IV. Provider business mailing address

15255 N 40TH ST
PHOENIX AZ
85032-4624
US

V. Phone/Fax

Practice location:
  • Phone: 646-752-4685
  • Fax:
Mailing address:
  • Phone: 646-752-4685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ESSAM ALI
Title or Position: PRESIDENT/DOCTOR
Credential: MD
Phone: 646-752-4685