=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154738193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESIDENTIAL HEALTHCARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2014
-----------------------------------------------------
Last Update Date | 07/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5215 LOUGHBORO ROAD NW SUITE 470
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-537-1100
-----------------------------------------------------
Fax | 202-537-1101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 HOBAN ROAD NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-537-1100
-----------------------------------------------------
Fax | 202-537-1101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JEFFREY A ELTING
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 202-537-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD34021
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------