Provider Demographics
NPI:1073538823
Name:ELLICHMAN, JONATHAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:J
Last Name:ELLICHMAN
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 1:1779 KIRBY PKWY # 1-511
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3666
Mailing Address - Country:US
Mailing Address - Phone:901-371-5218
Mailing Address - Fax:901-682-1785
Practice Address - Street 1:6401 POPLAR AVE STE 410
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4808
Practice Address - Country:US
Practice Address - Phone:901-259-2718
Practice Address - Fax:901-259-1123
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS189722086S0129X
TN39618208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN30005342Medicaid
AR165449001Medicaid
MS06336753Medicaid
AR165449001Medicaid
MS06336753Medicaid
TN30005342Medicaid
TN30005342Medicare PIN