=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326392721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINA CAROLINE KLIMCHUCK M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2012
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75-25 WINCHESTER BLVD
-----------------------------------------------------
City | QUEENS VILLAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-464-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85-31 120TH APT 4D
-----------------------------------------------------
City | KEW GARDENS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 11415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-733-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 310129
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 281215
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------