Provider Demographics
NPI:1194390310
Name:ELLIOTT, BRANDON G
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:G
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 W CENTER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-2151
Mailing Address - Country:US
Mailing Address - Phone:989-895-4625
Mailing Address - Fax:989-895-4626
Practice Address - Street 1:1458 W CENTER RD STE 1
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2151
Practice Address - Country:US
Practice Address - Phone:989-895-4625
Practice Address - Fax:989-895-4626
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351047848390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program