Provider Demographics
NPI:1790707974
Name:GINGRICH, ELIZABETH B (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:GINGRICH
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 459
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-0459
Mailing Address - Country:US
Mailing Address - Phone:574-825-2146
Mailing Address - Fax:574-825-2146
Practice Address - Street 1:206 W. WARREN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-0459
Practice Address - Country:US
Practice Address - Phone:574-825-2146
Practice Address - Fax:574-825-2182
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043636A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200066650AMedicaid
IN080149881OtherR/R MEDICARE
IN200066650BMedicaid
IN223490FMedicare ID - Type UnspecifiedMILLERSBURG SITE
IN223520HMedicare ID - Type UnspecifiedMIDDLEBURY SIT
IN080149881OtherR/R MEDICARE