Basic Information
| Provider Information | |||||||||
| NPI: | 1124394945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGLOTHLIN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEAGE | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2002 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491204074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870200 | ||||||||
| FaxNumber: | 2696840199 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491204074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696870200 | ||||||||
| FaxNumber: | 2696840199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301108540 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1124394945 | 05 | MI | MEDICAID |