Healthcare Provider Details

I. General information

NPI: 1578805958
Provider Name (Legal Business Name): ELANA BANNERMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 DERRY RD
HUDSON NH
03051-3023
US

IV. Provider business mailing address

PO BOX 3677
NASHUA NH
03061-3677
US

V. Phone/Fax

Practice location:
  • Phone: 603-886-3979
  • Fax: 603-886-2898
Mailing address:
  • Phone: 603-577-7900
  • Fax: 603-577-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number18222
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18222
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: