Provider Demographics
NPI:1841399540
Name:GREATHOUSE, ELVIA A (MD)
Entity Type:Individual
Prefix:
First Name:ELVIA
Middle Name:A
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELVIA
Other - Middle Name:A
Other - Last Name:YAZMINE-MEDEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2403
Mailing Address - Country:US
Mailing Address - Phone:812-333-9650
Mailing Address - Fax:812-333-9680
Practice Address - Street 1:415 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2403
Practice Address - Country:US
Practice Address - Phone:812-333-9650
Practice Address - Fax:812-333-9680
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064349207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200890250Medicaid
IN263460AMedicare PIN
IN200890250Medicaid