Provider Demographics
NPI:1174637599
Name:MICHAEL R ELLEN MD PS
Entity Type:Organization
Organization Name:MICHAEL R ELLEN MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-754-3380
Mailing Address - Street 1:128 LILLY RD NE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5029
Mailing Address - Country:US
Mailing Address - Phone:360-754-3380
Mailing Address - Fax:
Practice Address - Street 1:128 LILLY RD NE
Practice Address - Street 2:SUITE 205
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5029
Practice Address - Country:US
Practice Address - Phone:360-754-3380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026526208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1105360Medicaid
WAAB05680Medicare ID - Type Unspecified
WA1105360Medicaid