1134292766 NPI number — RUSSELL L ELLIS MD

Table of content: DEIDRE E. SCHLETTER (NPI 1114480514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134292766 NPI number — RUSSELL L ELLIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
RUSSELL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134292766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 14TH AVE SE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35601-3368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-350-0362
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1103 16TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35601-3595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-350-0362
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X , with the licence number:  00022020 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009983450 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51507394 . This is a "BLUECROSS BLUESHIELD OF A" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 260050183 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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