Basic Information
| Provider Information | |||||||||
| NPI: | 1477636033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANNER | ||||||||
| FirstName: | ELLIOTT | ||||||||
| MiddleName: | MAKARY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE STE 700 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668622 | ||||||||
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| Practice Location | |||||||||
| Address1: | 930 MADISON AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014486650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 02/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 41528 | TN | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 003179565A | 05 | GA | MEDICAID | 1477636033 | 05 | MO | MEDICAID | 162929001 | 05 | AR | MEDICAID | 180617 | 05 | AL | MEDICAID | 3827927 | 05 | TN | MEDICAID | 01570301 | 05 | MS | MEDICAID |