Basic Information
| Provider Information | |||||||||
| NPI: | 1902004708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELSASS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEIDEL | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 063188 | GA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | 063188 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0902X | 063188 | GA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 207RI0011X | 063188 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 316796310S | 05 | GA | MEDICAID | 316796310U | 05 | GA | MEDICAID | 316796310V | 05 | GA | MEDICAID | 316796310T | 05 | GA | MEDICAID |