Basic Information
| Provider Information | |||||||||
| NPI: | 1497743025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELDER | ||||||||
| FirstName: | DONALD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 E ORANGE ST | ||||||||
| Address2: | |||||||||
| City: | HOOPESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609421802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172835644 | ||||||||
| FaxNumber: | 2172837432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 12/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD8089 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036106255 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0172078073 | 05 | IL | MEDICAID | 050005 | 05 | HI | MEDICAID |