Basic Information
Provider Information | |||||||||
NPI: | 1588074462 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLITON | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | STROM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STROM | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1821 S STOUGHTON RD | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537162257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082606000 | ||||||||
FaxNumber: | 6082606853 | ||||||||
Practice Location | |||||||||
Address1: | 1821 S STOUGHTON RD | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537162257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082606000 | ||||||||
FaxNumber: | 6082606853 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2014 | ||||||||
LastUpdateDate: | 08/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A142919 | CA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 74459 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 1588074462 | 05 | WI |   | MEDICAID |