Basic Information
| Provider Information | |||||||||
| NPI: | 1972770501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLIOT PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELLIOT EMERGENCY MEDICINE SPECIALISTS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ELLIOT WAY | ||||||||
| Address2: | ELLIOT EMERGENCY MEDICINE SPECIALISTS | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031033502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036632830 | ||||||||
| FaxNumber: | 6036631849 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ELLIOT WAY | ||||||||
| Address2: | ELLIOT EMERGENCY MEDICINE SPECIALISTS | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031033502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036632830 | ||||||||
| FaxNumber: | 6036631849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERMAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS AND FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6036634904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLIOT PROFESSIONAL SERVICES | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | RE6661 | 01 | NH | MEDICARE GROUP PIN | OTHER | CK3360 | 01 | RR MEDICARE GROUP PIN | OTHER |