Healthcare Provider Details

I. General information

NPI: 1083601827
Provider Name (Legal Business Name): THOMAS LEE ELY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 MADISON ST
CLARKSVILLE TN
37043-4990
US

IV. Provider business mailing address

2879 CARRIAGE WAY
CLARKSVILLE TN
37043-2853
US

V. Phone/Fax

Practice location:
  • Phone: 931-221-2278
  • Fax: 931-551-1027
Mailing address:
  • Phone: 931-358-4981
  • Fax: 931-551-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO 652
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: