Provider Demographics
NPI:1033412846
Name:RICHARD ALAN ELLIS M.D,
Entity Type:Organization
Organization Name:RICHARD ALAN ELLIS M.D,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONICA
Authorized Official - Middle Name:WOODS
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:901-755-7069
Mailing Address - Street 1:3066 FOUNTAINSIDE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7820
Mailing Address - Country:US
Mailing Address - Phone:901-755-7335
Mailing Address - Fax:901-755-7380
Practice Address - Street 1:3066 FOUNTAINSIDE DR STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7820
Practice Address - Country:US
Practice Address - Phone:901-755-7335
Practice Address - Fax:901-755-7380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD016474208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3026121OtherTENNESSEE MEDICAID
TN3026121OtherTENNESSEE MEDICAID
TNA99003Medicare UPIN