Provider Demographics
NPI:1144617630
Name:ELLIOTT, MITCHELL FORBES (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:FORBES
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 1:201 ABRAHAM FLEXNER WAY
Mailing Address - Street 2:RUDD HEART AND LUNG CTR., STE. 690
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202
Mailing Address - Country:US
Mailing Address - Phone:502-852-0132
Mailing Address - Fax:
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY
Practice Address - Street 2:RUDD HEART & LUNG CTR., STE. 690
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-852-0132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYR3764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program