Provider Demographics
NPI:1134435647
Name:ELITE PEDIATRIC AND ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:ELITE PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:RUSH
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-237-7754
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-0538
Mailing Address - Country:US
Mailing Address - Phone:901-516-4082
Mailing Address - Fax:901-377-1427
Practice Address - Street 1:214 LAKEVIEW RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9737
Practice Address - Country:US
Practice Address - Phone:901-516-4082
Practice Address - Fax:901-516-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty