Basic Information
| Provider Information | |||||||||
| NPI: | 1881858876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERTSEN | ||||||||
| FirstName: | ELENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311310 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1725 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311310 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 0101251153 | VA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 48798 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 55622 | MN | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 103I223230 | 01 | TN | MEDICARE | OTHER | ENROLLED | 05 | MN | MEDICAID | ENROLLED | 05 | IA | MEDICAID | Q003153 | 05 | TN | MEDICAID |