1174597934 NPI number — DR. JOE E ELLIS O.D.

Table of content: DR. JOE E ELLIS O.D. (NPI 1174597934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174597934 NPI number — DR. JOE E ELLIS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
JOE
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1174597934
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 256
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42025-0256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-527-7421
Provider Business Mailing Address Fax Number:
270-527-3118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42025-1123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-527-7421
Provider Business Practice Location Address Fax Number:
270-527-3118
Provider Enumeration Date:
02/16/2006

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: 152W00000X , with the licence number:  1073DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 1073DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 149794 . This is a "HEALTHLINK" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77010734 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000053519 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4349131 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: T54572 . This is a "BLUEGRASS FAMILY HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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