Provider Demographics
NPI:1073597845
Name:ELLIOT, MARK BRUCKEL (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BRUCKEL
Last Name:ELLIOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01262-0962
Mailing Address - Country:US
Mailing Address - Phone:413-551-7925
Mailing Address - Fax:413-728-5580
Practice Address - Street 1:48 MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01262-0962
Practice Address - Country:US
Practice Address - Phone:413-551-7925
Practice Address - Fax:413-728-5580
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2181132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7056413Medicaid
I05631Medicare UPIN
007056413Medicare ID - Type Unspecified