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General NPI Number Information
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NPI Number | 1073538823
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Entity Type | Individual
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Provider Name | JONATHAN J ELLICHMAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 03/08/2016
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Provider Practice Location Address
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Address Line | 6401 POPLAR AVE STE 410
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City | MEMPHIS
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State | TN
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Zip | 38119-4808
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Country | US
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Telephone | 901-259-2718
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Fax | 901-259-1123
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Provider Business Mailing Address
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Address Line | 1779 KIRBY PKWY # 1-511
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City | MEMPHIS
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State | TN
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Zip | 38138-3666
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Country | US
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Telephone | 901-371-5218
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Fax | 901-682-1785
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 18972
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 39618
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License Number State | TN
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