Basic Information
| Provider Information | |||||||||
| NPI: | 1396093290 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE SPECIALTY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4995 BRADENTON AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430173543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147345000 | ||||||||
| FaxNumber: | 6147345001 | ||||||||
| Practice Location | |||||||||
| Address1: | 4995 BRADENTON AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430173543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147345000 | ||||||||
| FaxNumber: | 6147345001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2012 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | DIXON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6147345000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 34005251 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.