Healthcare Provider Details

I. General information

NPI: 1154341147
Provider Name (Legal Business Name): ELIZABETH CHALOM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

IV. Provider business mailing address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

V. Phone/Fax

Practice location:
  • Phone: 651-291-2848
  • Fax: 651-602-6885
Mailing address:
  • Phone: 651-291-2848
  • Fax: 651-602-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number62759
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number66643
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: