Provider Demographics
NPI:1073597845
Name:ELLIOT, MARK BRUCKEL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRUCKEL
Last Name:ELLIOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:69 CHURCH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2771
Mailing Address - Country:US
Mailing Address - Phone:413-551-7925
Mailing Address - Fax:413-728-5580
Practice Address - Street 1:69 CHURCH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2771
Practice Address - Country:US
Practice Address - Phone:413-551-7925
Practice Address - Fax:413-728-5580
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2181132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7056413Medicaid
I05631Medicare UPIN
007056413Medicare ID - Type Unspecified