Provider Demographics
NPI:1174725279
Name:ELMORE, CODY MARIE (MD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:MARIE
Last Name:ELMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CODY
Other - Middle Name:MARIE
Other - Last Name:BERTSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2477
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062434A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000586464OtherANTHEM PROVIDER NUMBER
IN200902940Medicaid
INP00732688Medicare PIN
IN000000586464OtherANTHEM PROVIDER NUMBER