Healthcare Provider Details

I. General information

NPI: 1649535469
Provider Name (Legal Business Name): JACKSON C ELAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

PO BOX 1705 C B 8058
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1700
  • Fax: 314-362-9878
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2015032584
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: