Provider Demographics
NPI:1083610836
Name:ELLISON, ROBERT G (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:ELLISON
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 1:400 BALD HILL RD
Mailing Address - Street 2:STE 520
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1692
Mailing Address - Country:US
Mailing Address - Phone:401-793-8520
Mailing Address - Fax:401-793-8527
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:STE 520
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1692
Practice Address - Country:US
Practice Address - Phone:401-793-8520
Practice Address - Fax:401-793-8527
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD04969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRE04322Medicaid
MA2071151Medicaid
RIRE04322Medicaid
RI7008153Medicare ID - Type Unspecified