Provider Demographics
NPI:1962493718
Name:ELDEVICK, KAREN LEA (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LEA
Last Name:ELDEVICK
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 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:2820 ROOSEVELT ROAD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3834
Practice Address - Country:US
Practice Address - Phone:715-735-5225
Practice Address - Fax:715-735-5388
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64279-20207QA0505X
MI4301051670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080036025OtherRAILROAD MEDICARE
MI2674383Medicaid
MIKE051670OtherBCBS OF MICHIGAN
MI2674383Medicaid
MIKE051670OtherBCBS OF MICHIGAN
MI080036025OtherRAILROAD MEDICARE
WIK400223224Medicare Oscar/Certification