Provider Demographics
NPI:1336101534
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:WOUND MANAGEMENT CENTER
Other - Org Type:Other Name
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:603-663-4904
Mailing Address - Street 1:185 QUEEN CITY AVE
Mailing Address - Street 2:WOUND MANAGEMENT CENTER
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-7100
Mailing Address - Country:US
Mailing Address - Phone:603-663-3630
Mailing Address - Fax:603-663-3669
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:WOUND MANAGEMENT CENTER
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7100
Practice Address - Country:US
Practice Address - Phone:603-663-3630
Practice Address - Fax:603-663-3669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-04
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH207PE0005X
2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30212489Medicaid
NHCK3360OtherRR MEDICARE
NHCK3360OtherRR MEDICARE