Provider Demographics
NPI:1730188707
Name:SHAFER, ELAINE L (MD)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:L
Last Name:SHAFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E VISTULA ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-9489
Mailing Address - Country:US
Mailing Address - Phone:574-848-4427
Mailing Address - Fax:574-848-4592
Practice Address - Street 1:306 E VISTULA ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:IN
Practice Address - Zip Code:46507-9489
Practice Address - Country:US
Practice Address - Phone:574-848-4427
Practice Address - Fax:574-848-4592
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042902A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000109333OtherANTHEM BCBS # - FPA
IN000000313699OtherANTHEM BCBS # - FMC
IN000000109332OtherANTHEM BCBS # - BFP
MIHPM 39695Medicaid
IN000000536675OtherANTHEM BCBS # - OSC
MI0N9906003Medicare PIN
IN000000536675OtherANTHEM BCBS # - OSC
IN184640VMedicare PIN