| Southern Cardiovascular Pllc | |
|
6401 Poplar Ave Ste 410 Memphis TN 38119 | |
| (901) 259-2718 | |
| (901) 259-1123 |
| Full Name | Southern Cardiovascular Pllc |
|---|---|
| Speciality | Clinic/Center |
| Location | 6401 Poplar Ave Ste 410, Memphis, Tennessee |
| Authorized Official Name and Position | Jonathan Joe Ellichman (PRESIDENT) |
| Authorized Official Contact | 9012592718 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Cardiovascular Pllc Po Box 1135 Collierville TN 38027-1135 Ph: (901) 259-2718 | Southern Cardiovascular Pllc 6401 Poplar Ave Ste 410 Memphis TN 38119 Ph: (901) 259-2718 |
| NPI Number | 1447415104 |
|---|---|
| Provider Enumeration Date | 07/22/2008 |
| Last Update Date | 08/15/2018 |
| Medicare PECOS PAC ID | 0042388373 |
|---|---|
| Medicare Enrollment ID | O20081014000137 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1447415104 | NPI | - | NPPES |
| 1526038 | Medicaid | TN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Jonathan J Ellichman |
|---|---|
| Provider Type | Practitioner - Cardiac Surgery |
| Provider Identifiers | NPI Number: 1073538823 PECOS PAC ID: 1759395106 Enrollment ID: I20070908000167 |
| Provider Name | Gary Mantell |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1750305892 PECOS PAC ID: 9335219039 Enrollment ID: I20080606000722 |
| Provider Name | Jennifer Kirby |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598058356 PECOS PAC ID: 3375721046 Enrollment ID: I20110628000430 |
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