Provider Demographics
NPI:1164645008
Name:ELM STREET MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:ELM STREET MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:REISER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-344-1025
Mailing Address - Street 1:4921 W ELM ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4020
Mailing Address - Country:US
Mailing Address - Phone:815-344-1025
Mailing Address - Fax:815-344-1208
Practice Address - Street 1:4921 W ELM ST
Practice Address - Street 2:SUITE A
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4020
Practice Address - Country:US
Practice Address - Phone:815-344-1025
Practice Address - Fax:815-344-1208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038005010Medicaid
IL05632034OtherBLUE CROSS PROVIDER NUMBE
IL579590Medicare PIN
IL05632034OtherBLUE CROSS PROVIDER NUMBE