Provider Demographics
NPI:1174605513
Name:ELLINGSON, ERIC MATTHEW (MSPT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MATTHEW
Last Name:ELLINGSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LYME ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 LYME RD
Practice Address - Street 2:SUITE 303
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1219
Practice Address - Country:US
Practice Address - Phone:802-345-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3134225100000X
NHNH31342251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30394617Medicaid
VT1012982Medicaid
VT1012982Medicaid