Healthcare Provider Details

I. General information

NPI: 1013981042
Provider Name (Legal Business Name): WILLIAM R ELLIOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 RIVA RIDGE DR
MANSFIELD OH
44904-2127
US

IV. Provider business mailing address

1827 RIVA RIDGE DR
MANSFIELD OH
44904-2127
US

V. Phone/Fax

Practice location:
  • Phone: 419-617-4452
  • Fax: 419-617-1080
Mailing address:
  • Phone: 419-617-4452
  • Fax: 419-617-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number054178
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number054178
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME 89642
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 89642
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35063580
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: