=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649678780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL W. ELICE MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2014
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 CROSSWAYS PARK DR SUITE 200
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11797-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-802-5028
-----------------------------------------------------
Fax | 516-802-5027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 CROSSWAYS PARK DR SUITE 200
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11797-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-802-5028
-----------------------------------------------------
Fax | 516-802-5027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. MICHAEL W. ELICE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 506-802-5028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | 1325791
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------