Provider Demographics
NPI:1013006717
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:ELLIOT INTENSIVIST PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS & FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-663-4904
Mailing Address - Street 1:1 ELLIOT WAY
Mailing Address - Street 2:ELLIOT INTENSIVIST PROGRAM
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3502
Mailing Address - Country:US
Mailing Address - Phone:603-663-2231
Mailing Address - Fax:603-663-2353
Practice Address - Street 1:1 ELLIOT WAY
Practice Address - Street 2:ELLIOT INTENSIVIST PROGRAM
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3502
Practice Address - Country:US
Practice Address - Phone:603-663-2231
Practice Address - Fax:603-663-2353
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30234596Medicaid
NHCK3360OtherRR MEDICARE
NHRE6661Medicare ID - Type Unspecified