Basic Information
Provider Information | |||||||||
NPI: | 1871540567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLIOTT | ||||||||
FirstName: | CLARK | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2422 20TH ST SW | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584016201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012521050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2422 20TH ST SW | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584016201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012521050 | ||||||||
FaxNumber: | 7012523265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2006 | ||||||||
LastUpdateDate: | 01/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 41717 | KY | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YP0228X | 41717 | KY | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207Y00000X | 12266 | ND | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
No ID Information.