1770911950 NPI number — STEPHANIE STIFF ELLIMOOTTIL NP

Table of content: STEPHANIE STIFF ELLIMOOTTIL NP (NPI 1770911950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770911950 NPI number — STEPHANIE STIFF ELLIMOOTTIL NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIMOOTTIL
Provider First Name:
STEPHANIE
Provider Middle Name:
STIFF
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STIFF
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770911950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108-1633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-647-5299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 EAST MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
3RD FLOOR CARDIOVASCULAR CENTER RECP C
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48109-5864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-287-1082
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  209010837 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 4704326060 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)