Basic Information
| Provider Information | |||||||||
| NPI: | 1619910544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELFERVIG | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 01/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD009929 | TN | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | R4424 | AR | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 14866 | MS | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 14866 | MS | N | 207WX0107X | R4424 | AR | N | 207WX0107X | 9929 | TN | Y |
ID Information
| ID | Type | State | Issuer | Description | P00658339 | 01 | MS | PALMETTO RR MEDICARE | OTHER | 180024050 | 01 | TN | PALMETTO RR MEDICARE | OTHER | 00115592 | 05 | MS | MEDICAID | 107447001 | 05 | AR | MEDICAID | 3190249 | 05 | TN | MEDICAID | 202004503 | 05 | MO | MEDICAID |