Provider Demographics
NPI:1356560999
Name:ELITE MEDICAL GROUP
Entity type:Organization
Organization Name:ELITE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-663-4443
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0710
Mailing Address - Country:US
Mailing Address - Phone:309-663-4443
Mailing Address - Fax:
Practice Address - Street 1:3002 GILL ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3438
Practice Address - Country:US
Practice Address - Phone:309-663-4443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies