Healthcare Provider Details

I. General information

NPI: 1154248193
Provider Name (Legal Business Name): ELIANNA MARK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 VINE STREET
CINCINNATI OH
45221-0038
US

IV. Provider business mailing address

2901 FALLSTAFF RD UNIT 206
BALTIMORE MD
21209-3568
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberR241075
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: