Healthcare Provider Details

I. General information

NPI: 1932147774
Provider Name (Legal Business Name): THOMAS W ELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/25/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2863 HIGHWY 45 BYP
JACKSON TN
38305-3618
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-422-0213
  • Fax: 731-422-0410
Mailing address:
  • Phone: 731-425-5752
  • Fax: 731-425-5783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD8209
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberMD8209
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: