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General NPI Number Information
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NPI Number | 1538915210
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Entity Type | Organization
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Legal Business Name | ELITE OBSTETRICS AND GYNECOLOGY LLC
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Dates
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Enumeration Date | 04/24/2024
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Last Update Date | 05/06/2024
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Provider Practice Location Address
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Address Line | 225 PHYSICIANS PARK STE 305
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-3935
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Country | US
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Telephone | 573-772-4340
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 334
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City | VAN BUREN
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State | MO
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Zip | 63965-0334
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | TRACY GIBBS
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Credential |
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Telephone | 636-751-5598
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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