Provider Demographics
NPI:1003885930
Name:ELLER, ALVAN L (MD)
Entity Type:Individual
Prefix:
First Name:ALVAN
Middle Name:L
Last Name:ELLER
Suffix:
Gender:M
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: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:765-448-8335
Practice Address - Street 1:203 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IN
Practice Address - Zip Code:46929-1024
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8335
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022721A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100097620Medicaid
INEL17837008Medicaid
IN10825048OtherCAQH NUMBER
IN000000183530OtherANTHEM PROVIDER NUMBER
IN9057268OtherPHCS PID NUMBER
INB28378Medicare UPIN
IN142080NNMedicare PIN
IN815500H5Medicare PIN
IN815510ZMedicare PIN
IN815520GGMedicare PIN
IN142090RMedicare PIN
IN069320IMedicare PIN
IN9057268OtherPHCS PID NUMBER
IN10825048OtherCAQH NUMBER
INEL17837008Medicaid
IN090670LMedicare PIN
IN080121482Medicare PIN
IN199190SMedicare PIN
IN090680JMedicare PIN
IN069330KMedicare PIN