Provider Demographics
NPI:1588655567
Name:ELLIOT PHYSICIANS NETWORK
Entity Type:Organization
Organization Name:ELLIOT PHYSICIANS NETWORK
Other - Org Name:ELLIOT FAMILY MEDICINE AT GLEN LAKE
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 1:89 S MAST RD
Mailing Address - Street 2:ELLIOT FAMILY MEDICINE AT GLEN LAKE
Mailing Address - City:GOFFSTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03045-6102
Mailing Address - Country:US
Mailing Address - Phone:603-497-5661
Mailing Address - Fax:603-497-5740
Practice Address - Street 1:89 S MAST RD
Practice Address - Street 2:ELLIOT FAMILY MEDICINE AT GLEN LAKE
Practice Address - City:GOFFSTOWN
Practice Address - State:NH
Practice Address - Zip Code:03045-6102
Practice Address - Country:US
Practice Address - Phone:603-497-5661
Practice Address - Fax:603-497-5740
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PHYSICIANS NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-31
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30211110Medicaid
CG2227OtherRR MEDICARE GROUP
NHRE5600Medicare ID - Type UnspecifiedMEDICARE GROUP #