Provider Demographics
NPI:1104185552
Name:MARK P. ELAM, M.D., P.C.
Entity Type:Organization
Organization Name:MARK P. ELAM, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-226-4642
Mailing Address - Street 1:1575 CHATTANOOGA AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2671
Mailing Address - Country:US
Mailing Address - Phone:706-876-2186
Mailing Address - Fax:
Practice Address - Street 1:1115 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2628
Practice Address - Country:US
Practice Address - Phone:706-226-4642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036417314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000546532DMedicaid
GAF56607Medicare UPIN
GA11BDVGRMedicare PIN