Provider Demographics
NPI:1114185634
Name:FERLIC, ELISABETH A (MD)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:A
Last Name:FERLIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9720 S 1300 E
Mailing Address - Street 2:SUITE E230
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3712
Mailing Address - Country:US
Mailing Address - Phone:801-501-2950
Mailing Address - Fax:801-501-2951
Practice Address - Street 1:9720 S 1300 E
Practice Address - Street 2:SUITE E230
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3712
Practice Address - Country:US
Practice Address - Phone:801-501-2950
Practice Address - Fax:801-501-2951
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42235208800000X
MN56312208800000X
UT9017811-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ470009Medicaid
AZ470009Medicaid
AZZ133318Medicare PIN