1154465276 NPI number — ROBERT E ELLIS MD

Table of content: (NPI 1154465276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154465276 NPI number — ROBERT E ELLIS MD

Organization/Personal Information

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

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:
1154465276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9115 LEESGATE RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-5003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-719-0782
Provider Business Mailing Address Fax Number:
502-719-0787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9115 LEESGATE RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-719-0782
Provider Business Practice Location Address Fax Number:
502-719-0787
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
502-719-0782

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  19194 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1172028 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2441036000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CH0800 . This is a "MEDICARE RR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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