Healthcare Provider Details

I. General information

NPI: 1598756488
Provider Name (Legal Business Name): ELLIOT PHYSICIANS NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FREETOWN RD ELLIOT PEDIATRICS AND PRIMARY CARE AT RAYMOND
RAYMOND NH
03077-2358
US

IV. Provider business mailing address

15 FREETOWN RD ELLIOT PEDIATRICS AND PRIMARY CARE AT RAYMOND
RAYMOND NH
03077-2358
US

V. Phone/Fax

Practice location:
  • Phone: 603-895-8000
  • Fax: 603-895-8099
Mailing address:
  • Phone: 603-895-8000
  • Fax: 603-895-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier30211870
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer
# 2
IdentifierCG2227
Identifier TypeOTHER
Identifier StateNH
Identifier IssuerRR MEDICARE GROUP #

VIII. Authorized Official

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