Provider Demographics
NPI:1306802608
Name:DECATUR DIGESTIVE DISEASE CENTER LLC
Entity type:Organization
Organization Name:DECATUR DIGESTIVE DISEASE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ELOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-875-2640
Mailing Address - Street 1:2 MEMORIAL DR
Mailing Address - Street 2:SUITE 102 PHYSICIAN PLAZA WEST
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3950
Mailing Address - Country:US
Mailing Address - Phone:217-233-0003
Mailing Address - Fax:217-233-0077
Practice Address - Street 1:2 MEMORIAL DR
Practice Address - Street 2:SUITE 102 PYSICIAN PLAZA WEST
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3950
Practice Address - Country:US
Practice Address - Phone:217-233-0003
Practice Address - Fax:217-233-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00257307OtherMEDICARE RAILROAD
IL=========001Medicaid
IL=========001Medicaid