Basic Information
| Provider Information | |||||||||
| NPI: | 1548535628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADAMOVA | ||||||||
| FirstName: | YELIZAVETA | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADAMOV | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | V | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021293109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179525243 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4170 CITY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191311610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125903300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.