Provider Demographics
NPI:1326003179
Name:TAVIN, ELLIS (MD)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:
Last Name:TAVIN
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 1:8110 N BROTHER BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2760
Mailing Address - Country:US
Mailing Address - Phone:901-255-5221
Mailing Address - Fax:901-373-4511
Practice Address - Street 1:80 HUMPHREYS CENTER DR
Practice Address - Street 2:#100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-761-9030
Practice Address - Fax:901-473-6505
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601744208200000X
TN41308208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89100200Medicaid
TN3816514Medicare PIN
NC89100200Medicaid