Provider Demographics
NPI:1831342906
Name:ELLIOTT MEDICAL SERVICES, INC
Entity type:Organization
Organization Name:ELLIOTT MEDICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-640-9085
Mailing Address - Street 1:3334 W MAIN ST # 523
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4805
Mailing Address - Country:US
Mailing Address - Phone:405-640-9085
Mailing Address - Fax:405-360-5607
Practice Address - Street 1:122 E EUFAULA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6017
Practice Address - Country:US
Practice Address - Phone:405-640-9085
Practice Address - Fax:405-360-5607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2366208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100106530 CMedicaid