=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891999637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH RALEIGH D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 01/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 ROUTE 31 N STE 103
-----------------------------------------------------
City | PENNINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08534-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-730-1771
-----------------------------------------------------
Fax | 609-730-1274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 ROUTE 31 N STE 103
-----------------------------------------------------
City | PENNINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08534-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-730-1771
-----------------------------------------------------
Fax | 609-730-1274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB08494600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 25MB08494600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------