Healthcare Provider Details

I. General information

NPI: 1508825605
Provider Name (Legal Business Name): ERIC M ELLIOT DMSC, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 THACKERAY TRL STE 103
OCONOMOWOC WI
53066-4342
US

IV. Provider business mailing address

200 W SUMMIT AVE STE 290
WALES WI
53183-9427
US

V. Phone/Fax

Practice location:
  • Phone: 262-330-0062
  • Fax: 262-330-0062
Mailing address:
  • Phone: 844-726-3926
  • Fax: 857-364-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA850
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3443-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: