Provider Demographics
NPI:1548267693
Name:ELLIOTT, MICHAEL W II
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:ELLIOTT
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 W. CRAFT ST.
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1137
Mailing Address - Country:US
Mailing Address - Phone:618-546-5052
Mailing Address - Fax:618-544-2094
Practice Address - Street 1:807 W. CRAFT ST.
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1137
Practice Address - Country:US
Practice Address - Phone:618-546-5052
Practice Address - Fax:618-544-2094
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102103207Q00000X
IL036-102103261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102103Medicaid
148958Medicare Oscar/Certification
584060Medicare PIN
IL584060Medicare ID - Type Unspecified
IL036102103Medicaid