Provider Demographics
NPI:1154465276
Name:ROBERT E ELLIS MD
Entity Type:Organization
Organization Name:ROBERT E ELLIS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-719-0782
Mailing Address - Street 1:9115 LEESGATE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5003
Mailing Address - Country:US
Mailing Address - Phone:502-719-0782
Mailing Address - Fax:502-719-0787
Practice Address - Street 1:9115 LEESGATE RD
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5003
Practice Address - Country:US
Practice Address - Phone:502-719-0782
Practice Address - Fax:502-719-0787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1172028OtherPASSPORT HEALTH PLAN
KY2441036000OtherPASSPORT ADVANTAGE
KYCH0800OtherMEDICARE RR
KY2441036000OtherPASSPORT ADVANTAGE