1407833130 NPI number — CHARLES R ELLINGTON M.D.

Table of content: CHARLES R ELLINGTON M.D. (NPI 1407833130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407833130 NPI number — CHARLES R ELLINGTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLINGTON
Provider First Name:
CHARLES
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407833130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61820-3981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-366-1255
Provider Business Mailing Address Fax Number:
217-872-0849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
544 W PALMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARTHUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61911-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-281-3844
Provider Business Practice Location Address Fax Number:
217-353-3130
Provider Enumeration Date:
12/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036-101455 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036101455 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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