Individual
ELY JEAN SALON
Active
Individual
ELY JEAN SALON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
18381
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001722335
BLUE CROSS BLUE SHIELD
WV
05
—
0079492000
—
WV
01
—
2032422
MEDICATE PTAN
WV
Enumeration date
07/21/2006
Last updated
10/28/2010
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