Basic Information
| Provider Information | |||||||||
| NPI: | 1962493718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELDEVICK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1866 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543051866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 2820 ROOSEVELT ROAD | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541433834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157355225 | ||||||||
| FaxNumber: | 7157355388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 64279-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207Q00000X | 4301051670 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080036025 | 01 | MI | RAILROAD MEDICARE | OTHER | 2674383 | 05 | MI | MEDICAID | KE051670 | 01 | MI | BCBS OF MICHIGAN | OTHER |