Healthcare Provider Details

I. General information

NPI: 1932134533
Provider Name (Legal Business Name): ROSALIE ELENITSAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE STREET 2 MALONEY BUILDING
PHILADELPHIA PA
19104-4206
US

IV. Provider business mailing address

3400 SPRUCE STREET 2 MALONEY BLDG
PHILADELPHIA PA
19104-4206
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2737
  • Fax: 215-349-8339
Mailing address:
  • Phone: 215-662-2737
  • Fax: 215-349-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD037866E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD037866E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: