Basic Information
| Provider Information | |||||||||
| NPI: | 1255426391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | GERALD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 WEST BASSETT RD. | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174212663 | ||||||||
| FaxNumber: | 3178255305 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 WEST BASSETT RD. | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174212663 | ||||||||
| FaxNumber: | 3178255305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 07000949 | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200450000 | 05 | IN | MEDICAID | 200413870 | 05 | IN | MEDICAID |