Healthcare Provider Details

I. General information

NPI: 1104187442
Provider Name (Legal Business Name): ELLIOT PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MAMMOTH RD STE 1 ELLIOT PEDIATRIC UROLOGY
MANCHESTER NH
03109-4133
US

IV. Provider business mailing address

275 MAMMOTH RD STE 1 ELLIOT PEDIATRIC UROLOGY
MANCHESTER NH
03109-4133
US

V. Phone/Fax

Practice location:
  • Phone: 603-663-3222
  • Fax: 603-663-3229
Mailing address:
  • Phone: 603-663-3222
  • Fax: 603-663-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD P HERMAN
Title or Position: DIRECTOR OF OPERATIONS AND FINANCE
Credential:
Phone: 603-663-4904