MEDICARE: ELENA MODEL-RYBAKOVA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME92233	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7682202002	OTHER	FL	CIGNA PAL ID
2	28633	OTHER	FL	BCBS PROVIDER ID
3	7910755	OTHER	FL	AETNA PROVIDER ID
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891802815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELENA MODEL-RYBAKOVA M.D.

Provider Business Mailing Address
First Line	:	1009 BITTERSWEET BRANCH CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-5261
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1370 13TH AVE S
Second Line	:	STE 216
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3230
Country	:	US
Telephone Number	:	904-246-8480
Fax Number	:	904-246-8578

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	01/06/2011

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