Healthcare Provider Details

I. General information

NPI: 1083118764
Provider Name (Legal Business Name): ELAINA MOLTER SHADRACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROBERTA ELAINA MOLTER MD

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 W SAGINAW RD
SANFORD MI
48657-9206
US

IV. Provider business mailing address

4000 WELLNESS DR
MIDLAND MI
48670-2000
US

V. Phone/Fax

Practice location:
  • Phone: 989-687-9940
  • Fax:
Mailing address:
  • Phone: 844-832-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301508089
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.158218
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: