Provider Demographics
NPI:1932362670
Name:ELMS, KATHERINE RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:RENEE
Last Name:ELMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:RENEE
Other - Last Name:BOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3537 W FRONT ST STE G
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7943
Mailing Address - Country:US
Mailing Address - Phone:231-935-8827
Mailing Address - Fax:231-935-8837
Practice Address - Street 1:3537 W FRONT ST STE G
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7943
Practice Address - Country:US
Practice Address - Phone:231-935-8827
Practice Address - Fax:231-935-8837
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092780208000000X
IN01069528A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201022360Medicaid