Provider Demographics
NPI:1972579746
Name:ELLIOT PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:ELLIOT PROFESSIONAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS & 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 1:275 MAMMOTH RD STE 1
Mailing Address - Street 2:ELLIOT BREAST HEALTH CENTER
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-4133
Mailing Address - Country:US
Mailing Address - Phone:603-668-3067
Mailing Address - Fax:603-668-0164
Practice Address - Street 1:275 MAMMOTH RD STE 1
Practice Address - Street 2:ELLIOT BREAST HEALTH CENTER
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03109-4133
Practice Address - Country:US
Practice Address - Phone:603-668-3067
Practice Address - Fax:603-668-0164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIOT PROFESSIONAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-23
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHCK3360OtherRR MEDICARE GRP PIN
NH30212132Medicaid
NH30212132Medicaid