Provider Demographics
NPI:1104002815
Name:DR ELLIOTT YOLLES PSC
Entity Type:Organization
Organization Name:DR ELLIOTT YOLLES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:YOLLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-872-8772
Mailing Address - Street 1:2020 W 86TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1931
Mailing Address - Country:US
Mailing Address - Phone:317-872-8772
Mailing Address - Fax:317-872-2383
Practice Address - Street 1:2020 W 86TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1931
Practice Address - Country:US
Practice Address - Phone:317-872-8772
Practice Address - Fax:317-872-2383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. ELLIOTT YOLLES PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-11
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025241A207W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100057550Medicaid
IN064710Medicare PIN
INB28186Medicare UPIN
IN100057550Medicaid