Healthcare Provider Details

I. General information

NPI: 1750388351
Provider Name (Legal Business Name): ELIZABETH HAILU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROUTE 59 STE 103A
SUFFERN NY
10901-4927
US

IV. Provider business mailing address

153 W 11TH ST
NEW YORK NY
10011-8305
US

V. Phone/Fax

Practice location:
  • Phone: 800-207-5737
  • Fax: 610-401-2100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number237985
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02100461
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: