Basic Information
| Provider Information | |||||||||
| NPI: | 1992781132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELDER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | FREDERICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 SUNSET DR | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065484754 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064757000 | ||||||||
| FaxNumber: | 7064756676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 02/14/2018 | ||||||||
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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 | 207V00000X | 020098 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000188108B | 05 | GA | MEDICAID |