Provider Demographics
NPI:1083957088
Name:ELLIOTT, EDWARD C III
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:ELLIOTT
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEMORIAL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3999
Mailing Address - Country:US
Mailing Address - Phone:217-876-4830
Mailing Address - Fax:217-876-8385
Practice Address - Street 1:2 MEMORIAL DR STE 305
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3999
Practice Address - Country:US
Practice Address - Phone:217-876-4830
Practice Address - Fax:217-876-8385
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005738213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist