Basic Information
| Provider Information | |||||||||
| NPI: | 1083118764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADRACH | ||||||||
| FirstName: | ELAINA | ||||||||
| MiddleName: | MOLTER | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MOLTER | ||||||||
| OtherFirstName: | ROBERTA | ||||||||
| OtherMiddleName: | ELAINA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 37595 7 MILE RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481521003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348535694 | ||||||||
| FaxNumber: | 7344309388 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 S SWEETBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615232264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092742102 | ||||||||
| FaxNumber: | 3092743555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036.158218 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.