Provider Demographics
NPI:1215078142
Name:ELIAS, JULIE (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:ELIAS
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 1:2680 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4828
Mailing Address - Country:US
Mailing Address - Phone:269-324-2400
Mailing Address - Fax:269-324-0450
Practice Address - Street 1:2680 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4828
Practice Address - Country:US
Practice Address - Phone:269-324-2400
Practice Address - Fax:269-324-0450
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010888582080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C910950OtherBCBSM
MI1215078142Medicaid
MI4949250Medicaid