Provider Demographics
NPI:1336336940
Name:ELLIOTT OB GYN INC
Entity Type:Organization
Organization Name:ELLIOTT OB GYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-599-0055
Mailing Address - Street 1:1600 E RIVERVIEW AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NAPOLEON
Mailing Address - State:OH
Mailing Address - Zip Code:43545-9805
Mailing Address - Country:US
Mailing Address - Phone:419-599-0055
Mailing Address - Fax:419-599-0089
Practice Address - Street 1:1600 E RIVERVIEW AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9805
Practice Address - Country:US
Practice Address - Phone:419-599-0055
Practice Address - Fax:419-599-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085807174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2544189Medicaid
OH2544189Medicaid