Basic Information
| Provider Information | |||||||||
| NPI: | 1649444365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | CAROLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 7424 US HIGHWAY 64 STE 111 | ||||||||
| Address2: | |||||||||
| City: | BARTLETT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013723573 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 48574 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 48574 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528265 | 05 | TN | MEDICAID |