Basic Information
| Provider Information | |||||||||
| NPI: | 1972579746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELLIOT PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELLIOT BREAST HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 MAMMOTH RD STE 1 | ||||||||
| Address2: | ELLIOT BREAST HEALTH CENTER | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031094133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036683067 | ||||||||
| FaxNumber: | 6036680164 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 MAMMOTH RD STE 1 | ||||||||
| Address2: | ELLIOT BREAST HEALTH CENTER | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031094133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036683067 | ||||||||
| FaxNumber: | 6036680164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERMAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS & FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6036634904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLIOT PROFESSIONAL SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CK3360 | 01 | NH | RR MEDICARE GRP PIN | OTHER | 30212132 | 05 | NH | MEDICAID |