Provider Demographics
NPI:1841368651
Name:ELISEVICH, KONSTANTIN VOLOD (MD)
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:VOLOD
Last Name:ELISEVICH
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 6100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-267-7900
Practice Address - Fax:616-267-7901
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI060725207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI289182110Medicaid
700H262230OtherBLUE CROSS-BLUE CROSS
KE060725OtherCHAMPUS-CHAMPUS
KE060725OtherCOMMERCIAL-COMMERCIAL NUMBER
F45879Medicare UPIN
MI289182110Medicaid