Provider Demographics
NPI:1487690533
Name:ELLER, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:ELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 N ROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3600
Mailing Address - Country:US
Mailing Address - Phone:815-971-7600
Mailing Address - Fax:
Practice Address - Street 1:2350 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3600
Practice Address - Country:US
Practice Address - Phone:815-971-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058013207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058013OtherSTATE LICENSE
ILK10983Medicare PIN
IL036058013OtherSTATE LICENSE