Provider Demographics
NPI:1578567830
Name:ATTISHA, ELLIOTT S (DO)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:S
Last Name:ATTISHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32100 TELEGRAPH RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2452
Mailing Address - Country:US
Mailing Address - Phone:248-644-1221
Mailing Address - Fax:248-644-2748
Practice Address - Street 1:32100 TELEGRAPH RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2452
Practice Address - Country:US
Practice Address - Phone:248-644-1221
Practice Address - Fax:248-644-2748
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010136492080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI433451311Medicaid
MIH48707Medicare UPIN
MI0F36485026Medicare ID - Type UnspecifiedPROVIDER ID