Individual Professional Information |
|
NPI
|
1275714735
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
1951540343
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20160513000521
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
MCELVEEN
|
|
Individual professional last name
|
|
Provider First Name
|
RUSSELL
|
|
Individual professional first name
|
|
Provider Middle Name
|
L
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
Medical School Information |
|
Medical School Name
|
LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE, ERIE
|
|
Individual professional's medical school
|
|
Graduation Year
|
2006
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
CARDIAC SURGERY
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
EMERGENCY MEDICINE
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 2
|
PERIPHERAL VASCULAR DISEASE
|
|
Second secondary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 3
|
THORACIC SURGERY
|
|
Third secondary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 4
|
VASCULAR SURGERY
|
|
Fourth secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
EMERGENCY MEDICINE, PERIPHERAL VASCULAR DISEASE, THORACIC SURGERY, VASCULAR SURGERY
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
EPSS NORTH REGION LLC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
0345582474
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
14
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
600 E 1ST ST
|
|
Group Practice or individual's line 1 address
|
|
City
|
SPRING VALLEY
|
|
Group Practice or individual's city
|
|
State
|
IL
|
|
Group Practice or individual's state
|
|
Zip Code
|
613621512
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
8156645311
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
140164
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
MEMORIAL HOSPITAL OF CARBONDALE
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
141303
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
WARNER HOSPITAL AND HEALTH SERVICES
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
140011
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
SOUTHERN ILLINOIS HOSPITAL SERVICES DBA HERRIN HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
261314
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
HERMANN AREA DISTRICT HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
140143
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
ST MARGARETS HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|