Provider Demographics
NPI:1043295181
Name:ELLIS, GERRY FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:GERRY
Middle Name:FRANCIS
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 1:1304 13TH AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4359
Mailing Address - Country:US
Mailing Address - Phone:256-355-9216
Mailing Address - Fax:256-351-6327
Practice Address - Street 1:1304 13TH AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4359
Practice Address - Country:US
Practice Address - Phone:256-355-9216
Practice Address - Fax:256-351-6327
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8779207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D578OtherGROUP MEDICARE
AL51003190OtherBLUE CROSS BLUE SHIELD
52930017OtherGROUP ALABAMA MEDICAID
C74731Medicare UPIN
AL51003190OtherBLUE CROSS BLUE SHIELD