Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 4301088858 | MI |
NPI | 1215078142 |
---|---|
Provider Name | Julie Elias |
First Address | Portage, MI 49024-4828 |
Second Address | Portage, MI 49024-4828 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 06/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0C910950 | BCBSM (01) | MI |
1215078142 | (05) | MI |
4949250 | (05) | MI |