Basic Information
| Provider Information | |||||||||
| NPI: | 1780069138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE OB-GYN SERVICES OF EL PASO, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
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| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153727600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11040 VISTA DEL SOL DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799354314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155914624 | ||||||||
| FaxNumber: | 9155919291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | REBOK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153725004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 362686301 | 05 | TX | MEDICAID |