Provider Demographics
NPI:1902856164
Name:J B ELLIOT MD PC
Entity Type:Organization
Organization Name:J B ELLIOT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:BRUGLER
Authorized Official - Last Name:ELLIOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-427-3511
Mailing Address - Street 1:1201 SOUTH DR
Mailing Address - Street 2:STE 220
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3256
Mailing Address - Country:US
Mailing Address - Phone:989-773-3411
Mailing Address - Fax:989-775-3187
Practice Address - Street 1:1380 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EDMORE
Practice Address - State:MI
Practice Address - Zip Code:48829-8339
Practice Address - Country:US
Practice Address - Phone:989-427-3511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047281207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B47938Medicare UPIN