Provider Demographics
NPI:1033172242
Name:PERRICCI, ELLEN SMITH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:SMITH
Last Name:PERRICCI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 E ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2552
Mailing Address - Country:US
Mailing Address - Phone:734-477-7417
Mailing Address - Fax:
Practice Address - Street 1:2140 E ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2552
Practice Address - Country:US
Practice Address - Phone:734-477-7417
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010850212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1465377Medicaid
PA1465377Medicaid
B41257Medicare UPIN