Provider Demographics
NPI:1417544628
Name:NEWBERGER, ELIZABETH ROBIN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROBIN
Last Name:NEWBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 MACK AVE STE 2590
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2427
Mailing Address - Country:US
Mailing Address - Phone:313-577-1368
Mailing Address - Fax:
Practice Address - Street 1:259 MACK AVE STE 2590
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2427
Practice Address - Country:US
Practice Address - Phone:313-577-1368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010556363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant