Provider Demographics
NPI:1295952158
Name:MIDDY, ELIZABETH ANNE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MIDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 N BURGESS AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-3308
Mailing Address - Country:US
Mailing Address - Phone:614-279-9229
Mailing Address - Fax:
Practice Address - Street 1:272 N BURGESS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3308
Practice Address - Country:US
Practice Address - Phone:614-279-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2510492376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2525315OtherODMRDD CONTRACT NUMBER
OH2510492Medicaid