Provider Demographics
NPI:1699912139
Name:ELLIOT PHYSICIAN NETWORK
Entity type:Organization
Organization Name:ELLIOT PHYSICIAN NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION AND FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-663-4904
Mailing Address - Street 1:445 CYPRESS ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3600
Mailing Address - Country:US
Mailing Address - Phone:603-669-9450
Mailing Address - Fax:603-669-1858
Practice Address - Street 1:445 CYPRESS ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3600
Practice Address - Country:US
Practice Address - Phone:603-669-9450
Practice Address - Fax:603-669-1858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PHYSICIAN NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE5600OtherMEDICARE GROUP