Healthcare Provider Details

I. General information

NPI: 1497954911
Provider Name (Legal Business Name): ELYSE R. EISENBERG MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 FARMERS LN STE 10
SANTA ROSA CA
95405-6743
US

IV. Provider business mailing address

725 FARMERS LN STE 10
SANTA ROSA CA
95405-6743
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-5355
  • Fax: 866-870-0815
Mailing address:
  • Phone: 707-575-5355
  • Fax: 866-870-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG64542
License Number StateCA

VIII. Authorized Official

Name: DR. ELYSE RAE EISENBERG
Title or Position: CEO AND PRESIDENT
Credential: M.D.
Phone: 707-575-5355