Basic Information
| Provider Information | |||||||||
| NPI: | 1700816139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTIDIS | ||||||||
| FirstName: | ELIAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2655 RIDGEWAY AVE | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858658210 | ||||||||
| FaxNumber: | 5858657597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2655 RIDGEWAY AVE | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858658210 | ||||||||
| FaxNumber: | 5858657597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 211103 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01872260 | 05 | NY | MEDICAID | 2111037WIM | 01 | WORKERS COMP | OTHER |