Provider Demographics
NPI:1649444365
Name:ELLIOTT, ELIZABETH CAROLYN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CAROLYN
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 DEE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5408
Mailing Address - Country:US
Mailing Address - Phone:205-999-9485
Mailing Address - Fax:
Practice Address - Street 1:5339 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-8243
Practice Address - Country:US
Practice Address - Phone:901-271-9500
Practice Address - Fax:901-271-9501
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48574208000000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528265Medicaid
TN103I114218Medicare PIN