Basic Information
Provider Information | |||||||||
NPI: | 1407837057 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PLYLER | ||||||||
FirstName: | ELSIE | ||||||||
MiddleName: | DIANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 S BALLENGER HWY | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485323638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8103421000 | ||||||||
FaxNumber: | 8103421590 | ||||||||
Practice Location | |||||||||
Address1: | 2316 S CEDAR ST | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489103152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177024130 | ||||||||
FaxNumber: | 5177024139 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301049498 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0100174 | 01 | MI | PHYSICIANS HEALTH PLAN | OTHER | 4062824 | 01 | MI | AETNA | OTHER | 4509093 | 05 | MI |   | MEDICAID | 4439453 | 05 | MI |   | MEDICAID | 201486 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 201486 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | E49554 | 01 | MI | HEALTH NET FED SERVICES | OTHER | 4758123 | 05 | MI |   | MEDICAID |