Healthcare Provider Details

I. General information

NPI: 1295839629
Provider Name (Legal Business Name): GREGORY R ELLIOTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 BREMO RD SUITE 104
RICHMOND VA
23226-1934
US

IV. Provider business mailing address

5875 BREMO RD SUITE 104
RICHMOND VA
23226-1934
US

V. Phone/Fax

Practice location:
  • Phone: 804-287-7770
  • Fax: 804-287-7801
Mailing address:
  • Phone: 804-287-7770
  • Fax: 804-287-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101045949
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number0101045949
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: