Healthcare Provider Details

I. General information

NPI: 1326343625
Provider Name (Legal Business Name): ELLEN I EDGAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18975 COLLINS AVE UNIT 1602
SUNNY ISL BCH FL
33160-2357
US

IV. Provider business mailing address

1311 BRIGHTWATER AVE APT 18IJ
BROOKLYN NY
11235-5962
US

V. Phone/Fax

Practice location:
  • Phone: 718-790-7530
  • Fax: 717-544-4201
Mailing address:
  • Phone: 347-634-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME129771
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberME129771
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number259540
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: