Provider Demographics
NPI:1881858876
Name:GERTSEN, ELENA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:
Last Name:GERTSEN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6020
Mailing Address - Country:US
Mailing Address - Phone:423-431-1310
Mailing Address - Fax:
Practice Address - Street 1:1725 W MARKET ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6020
Practice Address - Country:US
Practice Address - Phone:423-431-1310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251153207ZP0102X
TN48798207ZP0102X
MN55622207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I223230OtherMEDICARE
MNENROLLEDMedicaid
IAENROLLEDMedicaid
TNQ003153Medicaid
MN220001631Medicare PIN