Provider Demographics
NPI:1336145317
Name:ELLIS, GARRETTSON S (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRETTSON
Middle Name:S
Last Name:ELLIS
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 1:5050 POPLAR AVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38157-0101
Mailing Address - Country:US
Mailing Address - Phone:901-276-2662
Mailing Address - Fax:901-274-1871
Practice Address - Street 1:5050 POPLAR AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38157-0101
Practice Address - Country:US
Practice Address - Phone:901-276-2662
Practice Address - Fax:901-274-1871
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38522207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN38943941OtherMEDICARE
TN3161384Medicaid
TN3161384Medicaid
TN38943941OtherMEDICARE