Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0000X | Obstetrician | 5101009256 | MI |
NPI | 1407954589 |
---|---|
Provider Name | Richard Elsworth |
First Address | Flint, MI 48503-5004 |
Second Address | Flint, MI 48503-5004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
112647368 | (05) | MI |
160B576250 | BLUE CROSS BLUE SHIELD (01) | MI |
F04783 | (02) | MI |