Healthcare Provider Details

I. General information

NPI: 1447415104
Provider Name (Legal Business Name): SOUTHERN CARDIOVASCULAR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 POPLAR AVE STE 410
MEMPHIS TN
38119
US

IV. Provider business mailing address

PO BOX 1135
COLLIERVILLE TN
38027-1135
US

V. Phone/Fax

Practice location:
  • Phone: 901-259-2718
  • Fax: 901-259-1123
Mailing address:
  • Phone: 901-259-2718
  • Fax: 901-259-1123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN JOE ELLICHMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 901-259-2718