Provider Demographics
NPI:1447365846
Name:ELLZEY, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ELLZEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 WOLF RIVER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1788
Mailing Address - Country:US
Mailing Address - Phone:901-747-1000
Mailing Address - Fax:901-747-1001
Practice Address - Street 1:6019 WALNUT GROVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-383-8860
Practice Address - Fax:901-383-1194
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN365892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142994001Medicaid
TN4065404OtherBCBS
TN3883156Medicaid
MO209040203Medicaid
MS00122829Medicaid
MSP00294088OtherRR MEDICARE
AR5L864OtherBCBS
TNP00032804OtherRR MEDICARE