Provider Demographics
NPI:1063482404
Name:ELLIOTT, CHARLES MCCARLEY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MCCARLEY
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 CITY AVE N
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1414
Mailing Address - Country:US
Mailing Address - Phone:662-837-1404
Mailing Address - Fax:662-837-3760
Practice Address - Street 1:1009 CITY AVE N
Practice Address - Street 2:SUITE A
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1414
Practice Address - Country:US
Practice Address - Phone:662-837-1404
Practice Address - Fax:662-837-3760
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0013009Medicaid
MS080003552Medicare ID - Type Unspecified
MS0013009Medicaid