Provider Demographics
NPI:1710985759
Name:CAPODICE, EFAW, OCHELTREE & ELGER PLLC
Entity Type:Organization
Organization Name:CAPODICE, EFAW, OCHELTREE & ELGER PLLC
Other - Org Name:DRS DORAN CAPODICE EFAW & OCHELTREE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KYNDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-663-2526
Mailing Address - Street 1:109 N REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3515
Mailing Address - Country:US
Mailing Address - Phone:309-663-2526
Mailing Address - Fax:309-663-4788
Practice Address - Street 1:109 N REGENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3515
Practice Address - Country:US
Practice Address - Phone:309-663-2526
Practice Address - Fax:309-663-4788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPODICE, EFAW, OCHELTREE & ELGER PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-13
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019018830Medicaid
IL019023548Medicaid
IL019022744Medicaid
IL019018830Medicaid
IL019023548Medicaid
IL019022744Medicaid
ILK13571Medicare PIN
ILF40908Medicare UPIN
ILU66652Medicare UPIN
ILT54148Medicare UPIN