MEDICARE: DR. ELENA GERTSEN M.D., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	0101251153	VA
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	48798	TN
3	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	55622	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103I223230	OTHER	TN	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881858876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELENA GERTSEN M.D., PH.D.

Provider Business Mailing Address
First Line	:	1725 W MARKET ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-6020
Country	:	US
Telephone Number	:	423-431-1310
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 W MARKET ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-6020
Country	:	US
Telephone Number	:	423-431-1310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2008
Last Update Date	:	08/09/2016

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Directions to “ DR. ELENA GERTSEN M.D., PH.D.” Practice Location

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