Provider Demographics
NPI:1437282787
Name:ELLEDGE, EMMETT SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMETT
Middle Name:SCOTT
Last Name:ELLEDGE
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 1:833 SAINT VINCENTS DR
Mailing Address - Street 2:STE 402
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1606
Mailing Address - Country:US
Mailing Address - Phone:205-933-9236
Mailing Address - Fax:205-933-9213
Practice Address - Street 1:833 SAINT VINCENTS DR
Practice Address - Street 2:SUITE 402
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1606
Practice Address - Country:US
Practice Address - Phone:205-933-9236
Practice Address - Fax:205-933-9236
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12962174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000024342Medicaid
AL000024342Medicaid
24342Medicare PIN
AL24342Medicare ID - Type UnspecifiedDR. ELLEDGE - MCR #