Healthcare Provider Details

I. General information

NPI: 1770057267
Provider Name (Legal Business Name): ERIC GERALD ELIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROUTE 112
CORAM NY
11727-4116
US

IV. Provider business mailing address

51 HILL ST
PATCHOGUE NY
11772-3207
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8302
  • Fax: 631-920-8462
Mailing address:
  • Phone: 215-987-8740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: