Healthcare Provider Details

I. General information

NPI: 1174207005
Provider Name (Legal Business Name): ROBERT J ELSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HAIRPIN DR
EDWARDSVILLE IL
62026-1000
US

IV. Provider business mailing address

507 CAMELOT DR
COLLINSVILLE IL
62234-4718
US

V. Phone/Fax

Practice location:
  • Phone: 618-650-5688
  • Fax:
Mailing address:
  • Phone: 661-476-7796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number041491458
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2022007959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: