Provider Demographics
NPI:1063468387
Name:DR. D. M. ELEM PC
Entity Type:Organization
Organization Name:DR. D. M. ELEM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DURENE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ELEM-VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-386-0000
Mailing Address - Street 1:1111 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1802
Mailing Address - Country:US
Mailing Address - Phone:313-386-0000
Mailing Address - Fax:313-386-1597
Practice Address - Street 1:1111 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1802
Practice Address - Country:US
Practice Address - Phone:313-386-0000
Practice Address - Fax:313-386-1597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001503213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4858252150OtherBLUE CROSS BLUE SHIELD MICHIGAN
MI2710766Medicaid
MIU16476Medicare UPIN
MI0P31910Medicare PIN
MI4858252150OtherBLUE CROSS BLUE SHIELD MICHIGAN