Provider Demographics
NPI:1588550891
Name:ELISE D FODOR, LLC
Entity type:Organization
Organization Name:ELISE D FODOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FODOR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:248-202-3599
Mailing Address - Street 1:4230 LOU MAR LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1905
Mailing Address - Country:US
Mailing Address - Phone:248-202-3599
Mailing Address - Fax:
Practice Address - Street 1:1380 COOLIDGE HWY STE 110
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-7067
Practice Address - Country:US
Practice Address - Phone:248-280-1867
Practice Address - Fax:248-280-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center