Provider Demographics
NPI:1255314951
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:ELLIOT OMS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS AND 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 OMS CENTER
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3502
Mailing Address - Country:US
Mailing Address - Phone:603-625-8462
Mailing Address - Fax:603-669-2711
Practice Address - Street 1:1 ELLIOT WAY
Practice Address - Street 2:ELLIOT OMS CENTER
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3502
Practice Address - Country:US
Practice Address - Phone:603-625-8462
Practice Address - Fax:603-669-2711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-28
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHCK3360OtherRR MEDICARE
NH30313860Medicaid
NHCK3360OtherRR MEDICARE