Provider Demographics
NPI:1053585513
Name:ARIC JAY ECKHARDT, M.D., S.C.
Entity type:Organization
Organization Name:ARIC JAY ECKHARDT, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIC
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ECKHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:309-764-4650
Mailing Address - Street 1:3900 28TH AVENUE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5536
Mailing Address - Country:US
Mailing Address - Phone:309-764-4650
Mailing Address - Fax:866-633-1827
Practice Address - Street 1:3900 28TH AVENUE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5536
Practice Address - Country:US
Practice Address - Phone:309-764-4650
Practice Address - Fax:866-633-1827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099360208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099360Medicaid
IL036099360Medicaid