=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841223633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLY SAMIR ELIAS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 11/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11715 ORPINGTON STREET, SUITE A TLC PEDIATRICS AND ADOLESCENT MEDICINE IN ASSOC WITH NE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-380-9115
-----------------------------------------------------
Fax | 407-380-9189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 191 PROVIDER ENROLLMENT DEPARTMENT
-----------------------------------------------------
City | ROCKLAND
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19732-0191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-651-4488
-----------------------------------------------------
Fax | 302-651-4945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME92588
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ME92584
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME92584
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------