Provider Demographics
NPI:1366483299
Name:ELIE MANSOUR, MD, PC
Entity Type:Organization
Organization Name:ELIE MANSOUR, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-562-4976
Mailing Address - Street 1:919 E CENTRAL AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-2777
Mailing Address - Country:US
Mailing Address - Phone:423-562-4976
Mailing Address - Fax:423-566-5896
Practice Address - Street 1:919 E CENTRAL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2777
Practice Address - Country:US
Practice Address - Phone:423-562-4976
Practice Address - Fax:423-566-5896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21870207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729357Medicare PIN