Provider Demographics
NPI:1508825605
Name:ELLIOT, ERIC M (DMSC, PA-C)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:ELLIOT
Suffix:
Gender:M
Credentials:DMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W SUMMIT AVE STE 290
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9427
Mailing Address - Country:US
Mailing Address - Phone:844-726-3926
Mailing Address - Fax:857-364-6016
Practice Address - Street 1:200 W SUMMIT AVE STE 290
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9427
Practice Address - Country:US
Practice Address - Phone:844-726-3926
Practice Address - Fax:844-726-3926
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA850363A00000X
WI3443-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1023800100Medicaid
ME154420000Medicaid
ME201300Medicare ID - Type UnspecifiedMEDICARE A - BHMH
MEAP2207Medicare ID - Type Unspecified
ME1023800100Medicaid
ME154420000Medicaid