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General NPI Number Information
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NPI Number | 1003225061
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Entity Type | Organization
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Legal Business Name | ELYSE R. EISENBERG, MD, INC.
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Dates
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Enumeration Date | 08/04/2014
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Last Update Date | 08/04/2014
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Provider Practice Location Address
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Address Line | 725 FARMERS LN STE 10
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City | SANTA ROSA
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State | CA
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Zip | 95405-6710
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Country | US
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Telephone | 707-523-3375
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Fax | 866-870-0815
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Provider Business Mailing Address
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Address Line | 2685 LESLIE RD
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City | SANTA ROSA
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State | CA
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Zip | 95404-9607
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Country | US
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Telephone | 707-477-6617
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Fax | 866-415-8441
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELYSE RAE EISENBERG
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Credential | M.D.
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Telephone | 707-523-3375
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | G64542
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License Number State | CA
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