Provider Demographics
NPI:1023036530
Name:ELLIS, ROBERT K (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
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 1:2310 CALIFORNIA ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-4163
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-4163
Practice Address - Fax:574-262-9650
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025493A207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112110AMedicaid
IN223420DMedicare ID - Type Unspecified
IN100112110AMedicaid