Provider Demographics
NPI:1700887841
Name:ELMORE, ALICIA (DO)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2015
Mailing Address - Country:US
Mailing Address - Phone:231-775-9741
Mailing Address - Fax:231-775-9333
Practice Address - Street 1:827 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2015
Practice Address - Country:US
Practice Address - Phone:231-775-9741
Practice Address - Fax:231-775-9333
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAE015895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI139141OtherPREFERRED CHOICE
MI080166353OtherRAILROAD MEDICARE
MI0858317624OtherBLUE CROSS/SHIELD INDIVID
MI4621647Medicaid
MI0H36303OtherBLUE CROSS/SHIELD GROUP
MI0H36303007Medicare PIN
MIL14937Medicare UPIN