Healthcare Provider Details

I. General information

NPI: 1154358380
Provider Name (Legal Business Name): MELVIN EHRHARDT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIRGINIA & FRANKLIN STREETS
NORMAL IL
61761
US

IV. Provider business mailing address

PO BOX 131
COLLISON IL
61831-0131
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-4321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier05721369
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBC/BS
# 2
Identifier036043487-2
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: