Provider Demographics
NPI:1629496203
Name:DAVIS, ELISSA (MD)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 MEMORIAL DR STE 340
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5373
Mailing Address - Country:US
Mailing Address - Phone:618-234-9884
Mailing Address - Fax:
Practice Address - Street 1:4700 MEMORIAL DR STE 350
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5373
Practice Address - Country:US
Practice Address - Phone:618-212-4414
Practice Address - Fax:618-235-9020
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036152355207X00000X, 207XS0106X
MI4301117482390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program