1821046780 NPI number — B KEITH ELLIS M. D.

Table of content: MS. JAYELEENE RACHELLE RADKE (NPI 1306590864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821046780 NPI number — B KEITH ELLIS M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
B
Provider Middle Name:
KEITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M. 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:
1821046780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16651 SOUTHWEST FWY
Provider Second Line Business Mailing Address:
MOB 1, SUITE 400
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77479-2345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-776-9500
Provider Business Mailing Address Fax Number:
713-400-7220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16651 SOUTHWEST FWY
Provider Second Line Business Practice Location Address:
MOB 1, SUITE 400
Provider Business Practice Location Address City Name:
SUGAR LAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77479-2345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-776-9500
Provider Business Practice Location Address Fax Number:
713-400-7220
Provider Enumeration Date:
05/04/2006

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: 207RC0000X , with the licence number:  L7368 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 166000306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166000303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166000304 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166000305 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821046780 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01301854 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8DJ181 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01086528 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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