Provider Demographics
NPI:1093864118
Name:ELLINGSON, ANDREW N (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:N
Last Name:ELLINGSON
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 1:615 VALLEY VIEW DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6180
Mailing Address - Country:US
Mailing Address - Phone:309-762-1072
Mailing Address - Fax:309-762-1094
Practice Address - Street 1:615 VALLEY VIEW DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6180
Practice Address - Country:US
Practice Address - Phone:309-762-1072
Practice Address - Fax:309-762-1094
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63797-202085N0700X, 2085R0202X
IL036-1172282085N0700X, 2085R0202X
IA358382085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK35906Medicare PIN
IAI19417Medicare PIN
IL209395003Medicare PIN
IL209395003Medicare PIN