Basic Information
| Provider Information | |||||||||
| NPI: | 1316904105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELACQUA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 JORDAN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121808343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182740476 | ||||||||
| FaxNumber: | 5182740497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 10/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 149514 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 141655014 | 01 | NY | EMPIRE PLAN | OTHER | 160007874 | 01 | NY | RAILROAD MEDICARE | OTHER | 16152 | 01 | NY | MVP | OTHER | 00858755 | 05 | NY | MEDICAID | 113801 | 01 | NY | WELLCARE | OTHER | 13801 | 01 | NY | GHIHMO | OTHER | 10000563 | 01 | NY | CDPHP | OTHER | 52E361 | 01 | NY | BLUE CROSS | OTHER | 000416081001 | 01 | NY | BLUE SHIELD | OTHER | 0015055 | 01 | NY | GHI | OTHER | 141655014 | 01 | NY | UNITED HEALTHCARE | OTHER | 0005361476 | 01 | NY | AETNA | OTHER | 040426006334 | 01 | NY | FIDELIS | OTHER | 00020780401 | 01 | NY | UNIVERA | OTHER |