Basic Information
| Provider Information | |||||||||
| NPI: | 1710932017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIMMELFARB | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 11/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD8191 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1509269 | 01 | TN | MEDICAID - MTI | OTHER | 4068857 | 01 | TN | BCBS | OTHER | 4200724 | 01 | TN | BCBS TN | OTHER | 64071590 | 01 | KY | KY MEDICAID | OTHER | 1509269 | 05 | TN | MEDICAID | 4068499 | 01 | TN | BCBS | OTHER | PENDING | 01 | TN | RAILROAD MEDICARE | OTHER | 4291392 | 01 | TN | BCBS - MTI | OTHER | 3161070 | 05 | TN | MEDICAID |