Provider Demographics
NPI:1821095084
Name:SEYMOUR, ELIZABETH MARYA (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARYA
Last Name:SEYMOUR
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 1:2529 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1912
Mailing Address - Country:US
Mailing Address - Phone:814-944-3569
Mailing Address - Fax:814-944-8201
Practice Address - Street 1:2529 BROAD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1912
Practice Address - Country:US
Practice Address - Phone:814-944-3569
Practice Address - Fax:814-944-8201
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-03
Last Update Date:2013-03-18
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
PAMD418861173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019504360002Medicaid
001630558OtherHIGHMARK
P00173700OtherRAILROAD MEDICARE
001630558OtherHIGHMARK
PA0019504360002Medicaid