Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 26524 | KY |
N | 207NP0225X | Pediatric Dermatologist | 26524 | KY |
N | 207NS0135X | Procedural Dermatology | 26524 | KY |
NPI | 1225063175 |
---|---|
Provider Name | Gerald W. Elliott |
First Address | Lexington, KY 40509-1827 |
Second Address | Lexington, KY 40509-1827 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 02/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36000818 | ASC MEDICAID LAB GROUP (01) | KY |
37903705 | MEDICAID LAB GROUP (01) | KY |
4000501 | MEDICARE LAB GROUP (01) | KY |
64265242 | (05) | KY |
ASC1019 | ASC MEDICARE GROUP (01) | KY |
CB5773 | RAILROAD MEDICARE GROUP (01) | KY |
E07384 | (02) |