Provider Demographics
NPI:1164935169
Name:ELEMENTAL MEDICAL CENTER LTD
Entity type:Organization
Organization Name:ELEMENTAL MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTINS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ADEOYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:331-330-9955
Mailing Address - Street 1:15010 S RAVINIA AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5353
Mailing Address - Country:US
Mailing Address - Phone:331-330-9955
Mailing Address - Fax:
Practice Address - Street 1:612 S WESTERN AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4682
Practice Address - Country:US
Practice Address - Phone:331-330-9955
Practice Address - Fax:708-892-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
IL0361038892084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103889Medicaid