Basic Information
Provider Information | |||||||||
NPI: | 1528107547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELIA | ||||||||
FirstName: | GABRIEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13008 | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489013008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5172536320 | ||||||||
FaxNumber: | 5172536321 | ||||||||
Practice Location | |||||||||
Address1: | 1200 E MICHIGAN AVE STE 700 | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489121837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3863645550 | ||||||||
FaxNumber: | 5173645549 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2007 | ||||||||
LastUpdateDate: | 02/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 4301095830 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 1063002 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | P00848492 | 01 | MI | MEDICARE RAILROAD | OTHER | 1103304272 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORK | OTHER | 200000024946 | 01 | MI | PHYSICIANS HEALTH PLAN-COMMERCIAL | OTHER | 1103304272 | 01 | MI | BLUE CARE NETWORK | OTHER | 200000024946 | 01 | MI | PHYSICIANS HEALTH PLAN-MEDICAID | OTHER | 9421467 | 01 | MI | AETNA | OTHER | 1063002 | 01 | MI | MCLAREN HEALTH PLAN COMMERCIAL | OTHER | 1063002 | 01 | MI | MCLAREN HEALTH PLAN MEDICAID | OTHER |