Provider Demographics
NPI:1124038047
Name:ELLIS, BRIAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
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:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40423-0990
Mailing Address - Country:US
Mailing Address - Phone:859-236-3361
Mailing Address - Fax:859-239-9484
Practice Address - Street 1:109 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2527
Practice Address - Country:US
Practice Address - Phone:859-236-3361
Practice Address - Fax:859-239-9484
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64293632Medicaid
KY0878504Medicare ID - Type Unspecified
KY64293632Medicaid