Provider Demographics
NPI:1669559035
Name:ELAM, MARK P (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:ELAM
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 1:208 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-3959
Mailing Address - Country:US
Mailing Address - Phone:706-483-4999
Mailing Address - Fax:
Practice Address - Street 1:9702 CHESTNUT HILL LN
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4815
Practice Address - Country:US
Practice Address - Phone:706-226-5446
Practice Address - Fax:866-230-8698
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036147174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00546532AMedicaid
GA00546532AMedicaid
GAF56607Medicare UPIN