Provider Demographics
NPI:1033288303
Name:LEAVELL, ELLEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:T
Last Name:LEAVELL
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 1:498 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5200
Mailing Address - Country:US
Mailing Address - Phone:732-735-1897
Mailing Address - Fax:
Practice Address - Street 1:498 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5200
Practice Address - Country:US
Practice Address - Phone:732-735-1897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA39427207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE37872Medicare UPIN