Provider Demographics
NPI:1235255118
Name:DAVID L ELLENS MD FACP LLC
Entity Type:Organization
Organization Name:DAVID L ELLENS MD FACP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-342-1573
Mailing Address - Street 1:6703 159TH ST STE 115
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1782
Mailing Address - Country:US
Mailing Address - Phone:708-342-1573
Mailing Address - Fax:
Practice Address - Street 1:6703 159TH ST STE 115
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1782
Practice Address - Country:US
Practice Address - Phone:708-342-1573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213191Medicare ID - Type Unspecified
ILG15396Medicare UPIN