Healthcare Provider Details

I. General information

NPI: 1497053599
Provider Name (Legal Business Name): ELLEN ELIZABETH CUDDEBACK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 09/07/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

1215 E MICHIGAN AVE
LANSING MI
48912-1896
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 517-364-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02004563A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101027648
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: