Basic Information
| Provider Information | |||||||||
| NPI: | 1003885930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLER | ||||||||
| FirstName: | ALVAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5545 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479035545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7654488335 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FLORA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469291024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7654488335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 09/29/2008 | ||||||||
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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 | 01022721A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100097620 | 05 | IN | MEDICAID | EL17837008 | 05 | IN | MEDICAID | 10825048 | 01 | IN | CAQH NUMBER | OTHER | 000000183530 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 9057268 | 01 | IN | PHCS PID NUMBER | OTHER |