Provider Demographics
NPI:1518089671
Name:WALSH, ELONA MARY (DC)
Entity Type:Individual
Prefix:DR
First Name:ELONA
Middle Name:MARY
Last Name:WALSH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 N CENTRAL PARK AVE
Mailing Address - Street 2:# 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5604
Mailing Address - Country:US
Mailing Address - Phone:773-539-5651
Mailing Address - Fax:
Practice Address - Street 1:3070 N LAKE TER
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1335
Practice Address - Country:US
Practice Address - Phone:708-997-6221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01627839OtherBLUE CROSS & BLUE SHIELD
IL705160Medicare ID - Type Unspecified