Provider Demographics
NPI:1295839629
Name:ELLIOTT, GREGORY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5875 BREMO RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-287-7770
Mailing Address - Fax:804-287-7801
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-287-7770
Practice Address - Fax:804-287-7801
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045949208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1295839629Medicaid
VAC06778OtherGROUP PTAN
VA021071B78Medicare PIN
D81965Medicare UPIN