Provider Demographics
NPI:1124196845
Name:ELLIS, CHARLES T (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
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 1:2047 N. LAST CHANCE GULCH #167
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601
Mailing Address - Country:US
Mailing Address - Phone:406-422-0414
Mailing Address - Fax:612-465-1397
Practice Address - Street 1:2600 WINNY AVE.
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601
Practice Address - Country:US
Practice Address - Phone:406-422-0414
Practice Address - Fax:612-465-1397
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT111962084P0800X
WAMD601917992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000914460OtherBLUE CROSS-SHIELD OF MONTANA
MT0000914460OtherBLUE CROSS-SHIELD OF MONTANA
MTF23556Medicare UPIN