Provider Demographics
NPI:1457385072
Name:ELDER, JACK S (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:S
Last Name:ELDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL
Mailing Address - Street 2:2E
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-916-2600
Mailing Address - Fax:313-916-9539
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:313-916-9539
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-053721208800000X
MI4301072611208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020H277290OtherBCBS
OH1900370OtherUHC
OH0633587Medicaid
OH000000026163OtherANTHEM
MI1396817714OtherGROUP NPI
PA001953975002Medicaid
MI5196618Medicaid
OHP00388789OtherRAILROAD MEDICARE
OHP00388789OtherRAILROAD MEDICARE
OH1900370OtherUHC
OHEL0584098Medicare PIN
MI020H277290OtherBCBS