Healthcare Provider Details

I. General information

NPI: 1932107349
Provider Name (Legal Business Name): JAMES KEVIN ELSEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DRIVE SUITE 300
LAWRENCEVILLE GA
30046-3371
US

IV. Provider business mailing address

631 PROFESSIONAL DRIVE SUITE 300
LAWRENCEVILLE GA
30046-3371
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-9977
  • Fax: 770-339-9804
Mailing address:
  • Phone: 770-962-9977
  • Fax: 770-339-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number021680
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: