Provider Demographics
NPI:1205821295
Name:ELLIOT PHYSICIANS NETWORK
Entity Type:Organization
Organization Name:ELLIOT PHYSICIANS NETWORK
Other - Org Name:DERRYFIELD MEDICAL GROUP
Other - Org Type:Doing Business As
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:603-663-5766
Mailing Address - Street 1:275 MAMMOTH RD STE 4
Mailing Address - Street 2:DERRYFIELD MEDICAL GROUP
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-4133
Mailing Address - Country:US
Mailing Address - Phone:603-624-4380
Mailing Address - Fax:603-624-4805
Practice Address - Street 1:275 MAMMOTH RD STE 4
Practice Address - Street 2:DERRYFIELD MEDICAL GROUP
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03109-4133
Practice Address - Country:US
Practice Address - Phone:603-624-4380
Practice Address - Fax:603-624-4805
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PHYSICIANS NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-15
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30210576Medicaid
NHCG2227OtherRR MEDICARE GROUP #
NHCG2227OtherRR MEDICARE GROUP #