Provider Demographics
NPI:1912255118
Name:ELLIOT PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:ELLIOT DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-663-4904
Mailing Address - Street 1:185 QUEEN CITY AVE
Mailing Address - Street 2:ELLIOT DERMATOLOGY
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-7121
Mailing Address - Country:US
Mailing Address - Phone:603-314-6930
Mailing Address - Fax:603-314-6939
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:ELLIOT DERMATOLOGY
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7121
Practice Address - Country:US
Practice Address - Phone:603-314-6930
Practice Address - Fax:603-314-6939
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty