Provider Demographics
NPI:1538140660
Name:ELLIOT PHYSICIANS NETWORK
Entity Type:Organization
Organization Name:ELLIOT PHYSICIANS NETWORK
Other - Org Name:ELLIOT PEDIATRICS AND PRIMARY CARE AT RIVERSIDE
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 1:11 KIMBALL DR
Mailing Address - Street 2:ELLIOT PEDIATRICS AND PRIMARY CARE AT RIVERSIDE
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106-2603
Mailing Address - Country:US
Mailing Address - Phone:603-641-5386
Mailing Address - Fax:603-641-5387
Practice Address - Street 1:11 KIMBALL DR
Practice Address - Street 2:ELLIOT PEDIATRICS AND PRIMARY CARE AT RIVERSIDE
Practice Address - City:HOOKSETT
Practice Address - State:NH
Practice Address - Zip Code:03106-2603
Practice Address - Country:US
Practice Address - Phone:603-641-5386
Practice Address - Fax:603-641-5387
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PHYSICIANS NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-07
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHCG2227OtherRR MEDICARE GROUP #
NH30211437Medicaid
NH30211437Medicaid