Provider Demographics
NPI:1114107976
Name:ELLIS J TALBERT, MD SC
Entity Type:Organization
Organization Name:ELLIS J TALBERT, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:TALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-986-5106
Mailing Address - Street 1:7000 S ADAMS ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8453
Mailing Address - Country:US
Mailing Address - Phone:630-986-5106
Mailing Address - Fax:630-986-5119
Practice Address - Street 1:7000 S ADAMS ST
Practice Address - Street 2:SUITE 240
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-8453
Practice Address - Country:US
Practice Address - Phone:630-986-5106
Practice Address - Fax:630-986-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211174Medicare PIN