Provider Demographics
NPI:1073567178
Name:ELSEN, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:ELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-8614
Practice Address - Country:US
Practice Address - Phone:616-267-7015
Practice Address - Fax:616-267-7818
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3415608Medicaid
MI3418708Medicaid
MI2995030Medicaid
MI4160933Medicaid
MI4179050Medicaid
MI4876790Medicaid
MI4160933Medicaid
MI2995030Medicaid
MIB44288Medicare UPIN
MI4876790Medicaid