Healthcare Provider Details

I. General information

NPI: 1861845091
Provider Name (Legal Business Name): ELIZABETH DETROYER CM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3424 KOSSUTH AVE
BRONX NY
10467-2489
US

IV. Provider business mailing address

500 E 77TH ST APT 1008
NEW YORK NY
10162-0026
US

V. Phone/Fax

Practice location:
  • Phone: 718-519-3872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001740-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: