Provider Demographics
NPI:1871887661
Name:ELITE MEDICAL, PLLC
Entity type:Organization
Organization Name:ELITE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:DYE
Authorized Official - Last Name:HAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-205-4652
Mailing Address - Street 1:PO BOX 2484
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-2484
Mailing Address - Country:US
Mailing Address - Phone:662-205-4652
Mailing Address - Fax:662-205-4651
Practice Address - Street 1:2633 TRACELAND DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4238
Practice Address - Country:US
Practice Address - Phone:662-205-4652
Practice Address - Fax:662-205-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16935261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126275Medicaid
MS080003621Medicare PIN