Provider Demographics
NPI:1780650457
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:GREATER PAWTUCKAWAY IMAGING
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 1:15 FREETOWN RD
Mailing Address - Street 2:GREATER PAWTUCKAWAY IMAGING
Mailing Address - City:RAYMOND
Mailing Address - State:NH
Mailing Address - Zip Code:03077-2358
Mailing Address - Country:US
Mailing Address - Phone:603-895-8000
Mailing Address - Fax:603-895-8099
Practice Address - Street 1:15 FREETOWN RD
Practice Address - Street 2:GREATER PAWTUCKAWAY IMAGING
Practice Address - City:RAYMOND
Practice Address - State:NH
Practice Address - Zip Code:03077-2358
Practice Address - Country:US
Practice Address - Phone:603-895-8000
Practice Address - Fax:603-895-8099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-23
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3207928OtherAETNA GRP
NH667221OtherCIGNA GRP
NH696696OtherTUFTS GRP
NH30812254Medicaid
NHP00009327OtherRR MEDICARE GRP
NH601463704OtherW/C DOL GRP
NH626440OtherHPHC GRP
NH15Y002260NH02OtherANTHEM GRP ACES
NH15Y002260NH02OtherANTHEM GRP ACES