Provider Demographics
NPI:1417989237
Name:MICHAEL W ELLIOTT II MD
Entity Type:Organization
Organization Name:MICHAEL W ELLIOTT II MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RHC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-546-5052
Mailing Address - Street 1:807 W CRAFT ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454
Mailing Address - Country:US
Mailing Address - Phone:618-546-5052
Mailing Address - Fax:618-544-2094
Practice Address - Street 1:807 W CRAFT ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454
Practice Address - Country:US
Practice Address - Phone:618-546-5052
Practice Address - Fax:618-544-2094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102103Medicaid
IL=========001Medicaid
584060Medicare PIN
148958Medicare Oscar/Certification
G83376Medicare UPIN
IL=========001Medicaid