Provider Demographics
NPI:1740285121
Name:QUEEN, ELIZABETH PAIGE (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:PAIGE
Last Name:QUEEN
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 2546
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-2546
Mailing Address - Country:US
Mailing Address - Phone:706-259-4428
Mailing Address - Fax:706-226-2283
Practice Address - Street 1:1407 N THORNTON AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3093
Practice Address - Country:US
Practice Address - Phone:706-278-7224
Practice Address - Fax:706-275-6261
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG90725Medicare UPIN