=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174500623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURIE A ELLIOTT M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2005
-----------------------------------------------------
Last Update Date | 05/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3531 MARY ADER AVE SUITE C
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29414-5896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-556-0608
-----------------------------------------------------
Fax | 843-763-3997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3531 MARY ADER AVE SUITE C
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29414-5896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-556-0608
-----------------------------------------------------
Fax | 843-763-3997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 24981
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------