Healthcare Provider Details

I. General information

NPI: 1659744910
Provider Name (Legal Business Name): ADVANTAGE INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 PHAY AVE
CANON CITY CO
81212-2302
US

IV. Provider business mailing address

405 COLLIER RANCH RD
STEPHENVILLE TX
76401-1988
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR0034053
License Number StateCO

VIII. Authorized Official

Name: WILLIAM L ELZI
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 720-938-5022