Healthcare Provider Details

I. General information

NPI: 1538915210
Provider Name (Legal Business Name): ELITE OBSTETRICS AND GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 PHYSICIANS PARK STE 305
POPLAR BLUFF MO
63901-3935
US

IV. Provider business mailing address

PO BOX 334
VAN BUREN MO
63965-0334
US

V. Phone/Fax

Practice location:
  • Phone: 573-772-4340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRACY GIBBS
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 636-751-5598