Healthcare Provider Details

I. General information

NPI: 1033158191
Provider Name (Legal Business Name): MICHAEL C ELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 BUSINESS PARK CIR
GOODLETTSVILLE TN
37072-3132
US

IV. Provider business mailing address

3024 BUSINESS PARK CIR
GOODLETTSVILLE TN
37072-3132
US

V. Phone/Fax

Practice location:
  • Phone: 615-851-6033
  • Fax: 615-851-2018
Mailing address:
  • Phone: 615-851-6033
  • Fax: 615-851-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD11612
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: