Provider Demographics
NPI:1972520609
Name:ELLIOT DIAMOND
Entity type:Organization
Organization Name:ELLIOT DIAMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-923-2455
Mailing Address - Street 1:123 CHESTNUT ST.
Mailing Address - Street 2:STE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3051
Mailing Address - Country:US
Mailing Address - Phone:215-923-2455
Mailing Address - Fax:215-923-4535
Practice Address - Street 1:123 CHESTNUT ST
Practice Address - Street 2:STE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3051
Practice Address - Country:US
Practice Address - Phone:215-923-2455
Practice Address - Fax:215-923-4535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002164L213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000710490Medicaid
PAT29846Medicare UPIN
PA0180320001Medicare NSC
PA165687Medicare PIN