Provider Demographics
NPI:1093244907
Name:ELLIOTT, GLENN E
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 W ELK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-3787
Mailing Address - Country:US
Mailing Address - Phone:423-543-0073
Mailing Address - Fax:
Practice Address - Street 1:1500 W ELK AVE STE 104
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2655
Practice Address - Country:US
Practice Address - Phone:423-543-2215
Practice Address - Fax:423-543-2218
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6840208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation