Provider Demographics
NPI:1205066289
Name:ELISABETH NOELKE MD PA
Entity type:Organization
Organization Name:ELISABETH NOELKE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:NOELKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-617-9065
Mailing Address - Street 1:12 E TWOHIG AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6433
Mailing Address - Country:US
Mailing Address - Phone:325-617-9065
Mailing Address - Fax:
Practice Address - Street 1:12 E TWOHIG AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6433
Practice Address - Country:US
Practice Address - Phone:325-617-9065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211238501Medicaid
0025SJOtherBC/BS
TX111604802Medicaid
TX8F22613OtherMEDICARE PTAN RENDERING NPI
TX0A5094Medicare PIN