Healthcare Provider Details

I. General information

NPI: 1063482404
Provider Name (Legal Business Name): CHARLES MCCARLEY ELLIOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 CITY AVE N SUITE A
RIPLEY MS
38663-1414
US

IV. Provider business mailing address

1009 CITY AVE N SUITE A
RIPLEY MS
38663-1414
US

V. Phone/Fax

Practice location:
  • Phone: 662-837-1404
  • Fax: 662-837-3760
Mailing address:
  • Phone: 662-837-1404
  • Fax: 662-837-3760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05601
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: