Provider Demographics
NPI:1710956347
Name:ELLIOTT, KATHARINA E
Entity Type:Individual
Prefix:
First Name:KATHARINA
Middle Name:E
Last Name:ELLIOTT
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 1:601 JOHN ST
Mailing Address - Street 2:SUITE M005
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-6350
Mailing Address - Fax:269-341-8580
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M005
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-6350
Practice Address - Fax:269-341-8580
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010729762080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710956347Medicaid
3503904111OtherBCBS
MI4186840Medicaid
MI1417961137OtherBCBSM - BRONSON
G81820Medicare UPIN
MI4186840Medicaid