Healthcare Provider Details

I. General information

NPI: 1104185552
Provider Name (Legal Business Name): MARK P. ELAM, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 PROFESSIONAL BLVD
DALTON GA
30720-2628
US

IV. Provider business mailing address

1575 CHATTANOOGA AVE SUITE 2
DALTON GA
30720-2671
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-4642
  • Fax:
Mailing address:
  • Phone: 706-876-2186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number036417
License Number StateGA

VIII. Authorized Official

Name: DENNIS STOUT
Title or Position: ADMINISTRATOR
Credential:
Phone: 706-226-4642