Basic Information
| Provider Information | |||||||||
| NPI: | 1518986199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 17TH AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063202840 | ||||||||
| FaxNumber: | 2063202995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD00033595 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0039590 | 01 | WA | LABOR & INDUSTRY | OTHER | MD2863 | 01 | WA | AK DSHS | OTHER | 8227969 | 05 | WA | MEDICAID | EL4341 | 01 | WA | BLUE SHIELD | OTHER | US5277658 | 01 | WA | AETNA/USHC SPECIALIST | OTHER |