Provider Demographics
NPI:1619199072
Name:NIETERT, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NIETERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19644
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9644
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4485
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-3821
Practice Address - Fax:217-545-4485
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54439-020207N00000X
IL036-130434207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130434Medicaid
WI1619199072Medicaid
WI171400024OtherMEDICARE
WI54439-020OtherSTATE LICENSE
WI54439-020OtherSTATE LICENSE
WI54439-020OtherSTATE LICENSE