Healthcare Provider Details

I. General information

NPI: 1073538823
Provider Name (Legal Business Name): JONATHAN J ELLICHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 POPLAR AVE STE 410
MEMPHIS TN
38119-4808
US

IV. Provider business mailing address

1779 KIRBY PKWY # 1-511
MEMPHIS TN
38138-3666
US

V. Phone/Fax

Practice location:
  • Phone: 901-259-2718
  • Fax: 901-259-1123
Mailing address:
  • Phone: 901-371-5218
  • Fax: 901-682-1785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number18972
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number39618
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: