Provider Demographics
NPI:1871538314
Name:MEADOWS, ELLEN C (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:MEADOWS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:C
Other - Last Name:CAVENAGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-2315
Practice Address - Fax:517-372-1617
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010631152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1600140OtherPHP
MI3003317232OtherBCBS MI INDIVIDUAL PIN
0C36027014Medicare ID - Type Unspecified
MI0C36350074Medicare PIN
MI3077331Medicare ID - Type Unspecified
MI3003317232OtherBCBS MI INDIVIDUAL PIN