Provider Demographics
NPI:1528389780
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:NICU FOLLOW UP PROGRAM
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 1:275 MAMMOTH RD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-4133
Mailing Address - Country:US
Mailing Address - Phone:603-663-4539
Mailing Address - Fax:603-663-3982
Practice Address - Street 1:275 MAMMOTH RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03109-4133
Practice Address - Country:US
Practice Address - Phone:603-663-4539
Practice Address - Fax:603-663-3982
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE6661OtherMEDICARE GROUP