Basic Information
| Provider Information | |||||||||
| NPI: | 1669454344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 POCKET RD | ||||||||
| Address2: | |||||||||
| City: | HURT | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245632023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343249150 | ||||||||
| FaxNumber: | 4343248248 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 POCKET RD | ||||||||
| Address2: | |||||||||
| City: | HURT | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245632023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343249150 | ||||||||
| FaxNumber: | 4343248248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101038619 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005618789 | 05 | VA | MEDICAID | 080124260 | 01 | VA | MEDICARE RAILROAD | OTHER | 240963 | 01 | VA | ANTHEM | OTHER |