Provider Demographics
NPI:1750545786
Name:MUSGRAVE, EMILY ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ELIZABETH
Last Name:MUSGRAVE
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 1:3041 W US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-9280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3041 W US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9280
Practice Address - Country:US
Practice Address - Phone:765-778-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126552207Q00000X
IN02004492A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201248500Medicaid
IL036126552Medicaid
IN201248500Medicaid
206147OtherMEDICARE PTAN (GROUP)