Provider Demographics
NPI:1700114501
Name:ELLIOT M. LIVSTONE, MD, PA
Entity Type:Organization
Organization Name:ELLIOT M. LIVSTONE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIVSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-955-0000
Mailing Address - Street 1:1515 S OSPREY AVE
Mailing Address - Street 2:SUITE C11
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2939
Mailing Address - Country:US
Mailing Address - Phone:941-955-0000
Mailing Address - Fax:
Practice Address - Street 1:1515 S OSPREY AVE
Practice Address - Street 2:SUITE C11
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2939
Practice Address - Country:US
Practice Address - Phone:941-955-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042953207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D0955291OtherCLIA 10D0955291
FL58421OtherBC/BS
FL6790096001OtherCIGNA
FLP1647052OtherOXFORD
FL0508193OtherAETNA
FL2400764OtherGHI
FL10714272OtherCAQH
FL01103041OtherAMERIGROUP
FL100011714OtherRR MEDICARE
FLD86104Medicare UPIN
FL58421Medicare PIN