Healthcare Provider Details

I. General information

NPI: 1326003179
Provider Name (Legal Business Name): ELLIS TAVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 HUMPHREYS CENTER DR #100
MEMPHIS TN
38120
US

IV. Provider business mailing address

8110 N BROTHER BLVD STE 200
BARTLETT TN
38133-2760
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-9030
  • Fax: 901-473-6505
Mailing address:
  • Phone: 901-255-5221
  • Fax: 901-373-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number9601744
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number41308
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: