Provider Demographics
NPI:1205817327
Name:PROUT, ELIZABETH PARKS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:PARKS
Last Name:PROUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:PEARL
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9258
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILA - GASTRO & NUTRITION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-3247
Practice Address - Fax:215-590-3606
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213338208000000X
PAMD4318912080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H67200Medicare UPIN