Healthcare Provider Details

I. General information

NPI: 1902856164
Provider Name (Legal Business Name): J B ELLIOT MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 E MAIN ST
EDMORE MI
48829-8339
US

IV. Provider business mailing address

1201 SOUTH DR STE 220
MT PLEASANT MI
48858-3256
US

V. Phone/Fax

Practice location:
  • Phone: 989-427-3511
  • Fax:
Mailing address:
  • Phone: 989-773-3411
  • Fax: 989-775-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301047281
License Number StateMI

VIII. Authorized Official

Name: JERRY BRUGLER ELLIOT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 989-427-3511