Basic Information
| Provider Information | |||||||||
| NPI: | 1730133588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194150 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247013306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043271100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 13508 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000143660 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | P00309253 | 01 | RR MEDICARE BLUEFIELD | OTHER | 1003314 | 01 | WV | BRICKSTREET | OTHER | 3001609 | 01 | WV | BRICKSTREET | OTHER | 001827970 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 0056780000 | 05 | WV | MEDICAID | 010283205 | 05 | VA | MEDICAID |