Provider Demographics
NPI:1346402161
Name:SANDRA Y ELLIOTT MD INC
Entity Type:Organization
Organization Name:SANDRA Y ELLIOTT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-421-4514
Mailing Address - Street 1:3501 MACCORKLE AVE SE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1419
Mailing Address - Country:US
Mailing Address - Phone:304-421-4514
Mailing Address - Fax:877-893-7441
Practice Address - Street 1:3501 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1419
Practice Address - Country:US
Practice Address - Phone:304-421-4514
Practice Address - Fax:877-893-7441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15724174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9368061Medicare PIN