Provider Demographics
NPI:1255426391
Name:ELLIOTT, BRIAN GERALD (DPM)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:GERALD
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 WEST BASSETT RD.
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176
Mailing Address - Country:US
Mailing Address - Phone:317-421-2663
Mailing Address - Fax:317-825-5305
Practice Address - Street 1:275 WEST BASSETT RD.
Practice Address - Street 2:SUITE 4
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176
Practice Address - Country:US
Practice Address - Phone:317-421-2663
Practice Address - Fax:317-825-5305
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000949213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200450000Medicaid
IN200413870Medicaid
480034934Medicare PIN
IN151560C5Medicare PIN
P00221966Medicare PIN
IN200450000Medicaid
480034933Medicare PIN