Healthcare Provider Details

I. General information

NPI: 1114919487
Provider Name (Legal Business Name): JAMES T ELLIOTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E BROADWAY STE 300
COLUMBIA MO
65201-8023
US

IV. Provider business mailing address

1605 E BROADWAY SUITE 300
COLUMBIA MO
65201-8023
US

V. Phone/Fax

Practice location:
  • Phone: 573-256-7700
  • Fax: 573-256-3003
Mailing address:
  • Phone: 573-256-7700
  • Fax: 573-256-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number118289
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: