Healthcare Provider Details

I. General information

NPI: 1295439461
Provider Name (Legal Business Name): ELISE MARIE CHARRON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 AURORA DR
PINGREE GROVE IL
60140-6402
US

IV. Provider business mailing address

808 S WOOD ST RM 471
CHICAGO IL
60612-7300
US

V. Phone/Fax

Practice location:
  • Phone: 847-722-2696
  • Fax:
Mailing address:
  • Phone: 312-355-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036179098
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1295439461
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: