Provider Demographics
NPI:1922206929
Name:WELCH, ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:R
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 FORT JESSE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6286
Mailing Address - Country:US
Mailing Address - Phone:309-661-6290
Mailing Address - Fax:309-451-1354
Practice Address - Street 1:2200 FORT JESSE RD STE 110
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-661-6290
Practice Address - Fax:309-451-1354
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT-191048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
833120OtherMEDICARE GROUP #
833120OtherMEDICARE GROUP #