Provider Demographics
NPI:1134185564
Name:DECATUR DIGESTIVE DISEASE CENTER LLC
Entity type:Organization
Organization Name:DECATUR DIGESTIVE DISEASE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ELOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-233-0003
Mailing Address - Street 1:2 MEMORIAL DR SUITE 102
Mailing Address - Street 2:PHYSICIAN PLAZA WEST
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3950
Mailing Address - Country:US
Mailing Address - Phone:217-233-0003
Mailing Address - Fax:217-233-0077
Practice Address - Street 1:2 MEMORIAL DR SUITE 102
Practice Address - Street 2:PHYSICIAN PLAZA WEST
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3950
Practice Address - Country:US
Practice Address - Phone:217-233-0003
Practice Address - Fax:217-233-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002983261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50402OtherBLUE CROSS BLUE SHIELD
ILP00257307OtherMEDICARE RAILROAD
ILP00257307OtherMEDICARE RAILROAD
IL212201Medicare ID - Type Unspecified