Provider Demographics
NPI:1003918731
Name:ELLIS, ADAM WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:WESLEY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 NASHVILLE ST
Mailing Address - Street 2:STE 106
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-8889
Mailing Address - Country:US
Mailing Address - Phone:270-726-8090
Mailing Address - Fax:270-726-9008
Practice Address - Street 1:1623 NASHVILLE ST
Practice Address - Street 2:STE 106
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8889
Practice Address - Country:US
Practice Address - Phone:270-726-8090
Practice Address - Fax:270-726-9008
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40994208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33330911Medicare PIN