Provider Demographics
NPI:1023198298
Name:FOURTE, ELLIOTT MCKINLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:MCKINLEY
Last Name:FOURTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8836 S. ASHLAND
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620
Mailing Address - Country:US
Mailing Address - Phone:773-629-6036
Mailing Address - Fax:773-629-6852
Practice Address - Street 1:10661 S ROBERTS RD
Practice Address - Street 2:103
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1954
Practice Address - Country:US
Practice Address - Phone:708-974-9999
Practice Address - Fax:708-974-9985
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36117052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36117052OtherSTATE MEDICAL LICENSE