Provider Demographics
NPI:1407161151
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:ELLIOT GASTROENTEROLOGY
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:603-663-4904
Mailing Address - Street 1:185 QUEEN CITY AVE
Mailing Address - Street 2:ELLIOT GASTROENTEROLOGY
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-7100
Mailing Address - Country:US
Mailing Address - Phone:603-314-6900
Mailing Address - Fax:603-314-6909
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:ELLIOT GASTROENTEROLOGY
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7100
Practice Address - Country:US
Practice Address - Phone:603-314-6900
Practice Address - Fax:603-314-6909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-18
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE6661OtherMEDICARE GROUP