Provider Demographics
NPI:1013919174
Name:ELLIOTT, JAMES SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:SHANNON
Last Name:ELLIOTT
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 1:105 CHAMBLISS DR
Mailing Address - Street 2:
Mailing Address - City:HARDINSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40143-2575
Mailing Address - Country:US
Mailing Address - Phone:270-756-2424
Mailing Address - Fax:
Practice Address - Street 1:105 CHAMBLISS DR
Practice Address - Street 2:
Practice Address - City:HARDINSBURG
Practice Address - State:KY
Practice Address - Zip Code:40143-2575
Practice Address - Country:US
Practice Address - Phone:270-756-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2008-12-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-05-04
Provider Licenses
StateLicense IDTaxonomies
KY38786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY38786OtherLICENSE