Provider Demographics
NPI:1932265634
Name:PHILIP, ELSEWORTH LLEWELLYN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ELSEWORTH
Middle Name:LLEWELLYN
Last Name:PHILIP
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 STREAMWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1345
Mailing Address - Country:US
Mailing Address - Phone:708-720-2254
Mailing Address - Fax:708-720-2264
Practice Address - Street 1:102 E CULVER RD
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2216
Practice Address - Country:US
Practice Address - Phone:574-772-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038135146D00000X
IL146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE-460-77Medicare UPIN
IL972120Medicare ID - Type Unspecified