Provider Demographics
NPI:1083118764
Name:SHADRACH, ELAINA MOLTER (MD)
Entity Type:Individual
Prefix:
First Name:ELAINA
Middle Name:MOLTER
Last Name:SHADRACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:ELAINA
Other - Last Name:MOLTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2434 E CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-8503
Mailing Address - Country:US
Mailing Address - Phone:231-330-8612
Mailing Address - Fax:
Practice Address - Street 1:4 COLUMBUS AVE STE 380
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6476
Practice Address - Country:US
Practice Address - Phone:989-393-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.158218207Q00000X
MI4301508089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine