Provider Demographics
NPI:1174536650
Name:VAN LAANEN, ELLEN E (DO)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:E
Last Name:VAN LAANEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4631
Mailing Address - Country:US
Mailing Address - Phone:906-776-9040
Mailing Address - Fax:906-774-7279
Practice Address - Street 1:440 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4631
Practice Address - Country:US
Practice Address - Phone:906-776-9040
Practice Address - Fax:906-774-7279
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30100100Medicaid
MI112121767Medicaid
WI30100100Medicaid
E25840Medicare UPIN
MIP38340005Medicare Oscar/Certification