Healthcare Provider Details

I. General information

NPI: 1629496203
Provider Name (Legal Business Name): ELISSA DAVIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 MEMORIAL DR STE 350
BELLEVILLE IL
62226-5373
US

IV. Provider business mailing address

4700 MEMORIAL DR STE 340
BELLEVILLE IL
62226-5373
US

V. Phone/Fax

Practice location:
  • Phone: 618-212-4414
  • Fax: 618-235-9020
Mailing address:
  • Phone: 618-234-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301117482
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036152355
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number036152355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: