Provider Demographics
NPI:1134230451
Name:AMBERSON, ELAINE S (MD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:S
Last Name:AMBERSON
Suffix:
Gender:F
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37384-0070
Mailing Address - Country:US
Mailing Address - Phone:423-710-4716
Mailing Address - Fax:
Practice Address - Street 1:1803 MOWBRAY PIKE
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-7109
Practice Address - Country:US
Practice Address - Phone:423-710-4716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14930207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3138635OtherBCBS
TN3029387Medicare ID - Type Unspecified
TN3138635OtherBCBS