Provider Demographics
NPI:1568447464
Name:HIX, ELLIOTT L JR (DO)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:L
Last Name:HIX
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 53
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:MO
Mailing Address - Zip Code:63555-9767
Mailing Address - Country:US
Mailing Address - Phone:660-465-8511
Mailing Address - Fax:660-465-2365
Practice Address - Street 1:RR 1 BOX 53
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-9767
Practice Address - Country:US
Practice Address - Phone:660-465-8511
Practice Address - Fax:660-465-2365
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5B78207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOD41731Medicare UPIN