Healthcare Provider Details

I. General information

NPI: 1902041783
Provider Name (Legal Business Name): ELAN MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 HUDSON ST STE 302A
HOBOKEN NJ
07030-5641
US

IV. Provider business mailing address

241 PROSPECT AVE
ORADELL NJ
07649-2316
US

V. Phone/Fax

Practice location:
  • Phone: 201-653-7450
  • Fax:
Mailing address:
  • Phone: 201-653-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA06653300
License Number StateNJ

VIII. Authorized Official

Name: MRS. ROXANA PEEKE
Title or Position: BILLING MANAGER
Credential:
Phone: 201-522-3205