Provider Demographics
NPI:1821182619
Name:TAM, ELIZABETH SUE (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:SUE
Last Name:TAM
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32764 OLDE FRANKLIN DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1746
Mailing Address - Country:US
Mailing Address - Phone:248-626-6242
Mailing Address - Fax:
Practice Address - Street 1:32764 OLDE FRANKLIN DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1746
Practice Address - Country:US
Practice Address - Phone:248-626-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI805356133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N42020Medicare ID - Type Unspecified