Provider Demographics
NPI:1124394945
Name:MCGLOTHLIN, ELIZABETH ANN (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:MCGLOTHLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:WEAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4074
Mailing Address - Country:US
Mailing Address - Phone:269-687-0200
Mailing Address - Fax:269-684-0199
Practice Address - Street 1:2002 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4074
Practice Address - Country:US
Practice Address - Phone:269-687-0200
Practice Address - Fax:269-684-0199
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108540207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124394945Medicaid