Healthcare Provider Details

I. General information

NPI: 1447516638
Provider Name (Legal Business Name): ELLEN MICHELLE MLOT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 SUMMIT ST
ELGIN IL
60120-4362
US

IV. Provider business mailing address

1015 SUMMIT STREET
ELGIN IL
60120
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-6888
  • Fax: 847-742-8544
Mailing address:
  • Phone: 847-742-6888
  • Fax: 847-742-8544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036138495
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: