Healthcare Provider Details

I. General information

NPI: 1003995879
Provider Name (Legal Business Name): ILENE ELKINS FIDEL D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6414 PARK HEIGHTS AVENUE G1
BALTIMORE MD
21215
US

IV. Provider business mailing address

6414 PARK HEIGHTS AVENUE SUITE G1
BALTIMORE MD
21215
US

V. Phone/Fax

Practice location:
  • Phone: 410-358-0060
  • Fax: 410-358-0103
Mailing address:
  • Phone: 410-358-0060
  • Fax: 410-358-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number01323
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberS01323
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: