Provider Demographics
NPI:1760444228
Name:ATHENS, ELLEN K (DO)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:K
Last Name:ATHENS
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:15100 S PLAZA DR
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-5203
Practice Address - Country:US
Practice Address - Phone:734-287-3700
Practice Address - Fax:734-287-1859
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2020-10-22
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Provider Licenses
StateLicense IDTaxonomies
MIEA007598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1323893Medicaid
MI1323893Medicaid
MIOH26109002Medicare ID - Type Unspecified