Provider Demographics
NPI:1790748119
Name:ELLIOTT, EDWARD C II (MD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:C
Last Name:ELLIOTT
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W. MCKINLEY AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-6600
Mailing Address - Fax:217-876-6606
Practice Address - Street 1:210 W. MCKINLEY AVE
Practice Address - Street 2:STE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-876-6600
Practice Address - Fax:217-876-6606
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0787352085R0001X
IL036078735207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-078735Medicaid
IL036078735Medicaid
IL036078735Medicaid
L52559Medicare PIN