Provider Demographics
NPI:1407833130
Name:ELLINGTON, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:ELLINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-1255
Mailing Address - Fax:217-872-0849
Practice Address - Street 1:544 W PALMER ST
Practice Address - Street 2:
Practice Address - City:ARTHUR
Practice Address - State:IL
Practice Address - Zip Code:61911-1240
Practice Address - Country:US
Practice Address - Phone:217-281-3844
Practice Address - Fax:217-353-3130
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101455Medicaid
ILL91552Medicare PIN
IL036101455Medicaid