Healthcare Provider Details

I. General information

NPI: 1568880243
Provider Name (Legal Business Name): ELLIOTT LHOSPITAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax: 618-351-4957
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036.149581
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: