Healthcare Provider Details

I. General information

NPI: 1699381996
Provider Name (Legal Business Name): ELLIOT SOL WEISSBLUTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 N OUTLOOK TRAIL
BIG SKY MT
59720
US

IV. Provider business mailing address

1199 S FEDERAL HWY STE 380
BOCA RATON FL
33432-7335
US

V. Phone/Fax

Practice location:
  • Phone: 312-925-4400
  • Fax: 312-925-4400
Mailing address:
  • Phone: 312-925-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberCOMPLETING
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: