Healthcare Provider Details

I. General information

NPI: 1144544958
Provider Name (Legal Business Name): ELIZABETH MEDICAL DIAGNOSTIC ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 MORRIS AVE STE 1
ELIZABETH NJ
07208-2904
US

IV. Provider business mailing address

469 MORRIS AVE STE 1
ELIZABETH NJ
07208-2904
US

V. Phone/Fax

Practice location:
  • Phone: 908-351-3535
  • Fax: 908-351-0161
Mailing address:
  • Phone: 908-351-3535
  • Fax: 908-351-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberMAO73645
License Number StateNJ

VIII. Authorized Official

Name: DR. ELENA DRAGUN
Title or Position: CEO
Credential: MD
Phone: 908-351-3535