Basic Information
Provider Information
NPI: 1659744910
EntityType: 2
ReplacementNPI:  
OrganizationName: ADVANTAGE INTERNAL MEDICINE
LastName:  
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Mailing Information
Address1: 405 COLLIER RANCH RD
Address2:  
City: STEPHENVILLE
State: TX
PostalCode: 764011988
CountryCode: US
TelephoneNumber: 7024533799
FaxNumber: 7024535741
Practice Location
Address1: 1338 PHAY AVE
Address2:  
City: CANON CITY
State: CO
PostalCode: 812122302
CountryCode: US
TelephoneNumber: 7024533799
FaxNumber: 7024535741
Other Information
ProviderEnumerationDate: 11/09/2015
LastUpdateDate: 08/18/2021
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: ELZI
AuthorizedOfficialFirstName: WILLIAM
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: SOLE OWNER
AuthorizedOfficialTelephone: 7209385022
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential: M.D.
NPICertificationDate: 08/18/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XDR0034053COY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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