Basic Information
| Provider Information | |||||||||
| NPI: | 1598914970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVER ELIZABETH | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | IYNAS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLIVER | ||||||||
| OtherFirstName: | TONY | ||||||||
| OtherMiddleName: | IYNAS | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1305 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1305 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053284973 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2008 | ||||||||
| LastUpdateDate: | 11/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2011022968 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2011022968 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 9197 | SD | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 9197 | SD | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1598914970 | 05 | MO | MEDICAID | 1598914970 | 05 | IL | MEDICAID |