Provider Demographics
NPI:1003841958
Name:ELLOWAY, RICHARD SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SCOTT
Last Name:ELLOWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:S
Other - Last Name:ELLOWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1401 MARVIN ROAD, NE
Mailing Address - Street 2:SUITE 307 PMB 266
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5709
Mailing Address - Country:US
Mailing Address - Phone:360-491-5055
Mailing Address - Fax:
Practice Address - Street 1:1010 S. SCHEUBER ROAD
Practice Address - Street 2:SUITE G
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8877
Practice Address - Country:US
Practice Address - Phone:360-330-8808
Practice Address - Fax:360-330-8816
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029202207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911639821OtherTAX ID
WA100005752OtherRR MEDICARE
WA58585OtherL&I WORKERS COMP
WAD20530OtherPACC
WAEL5942OtherBL CROSS BL SHIELD
WA1086933Medicaid
WA333154001OtherGROUP HEALTH
WAF28655Medicare UPIN
WA100005752Medicare ID - Type UnspecifiedRR MEDICARE
115000055Medicare PIN
WA911639821OtherTAX ID