Provider Demographics
NPI:1659376473
Name:ELLIOTT, BERNIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNIE
Middle Name:E
Last Name:ELLIOTT
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 1:1300 RIVER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-1356
Mailing Address - Country:US
Mailing Address - Phone:309-757-6226
Mailing Address - Fax:800-388-6750
Practice Address - Street 1:1300 RIVER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-1356
Practice Address - Country:US
Practice Address - Phone:309-757-6226
Practice Address - Fax:800-388-6750
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL86107Medicare ID - Type Unspecified
ILE92063Medicare UPIN