Provider Demographics
NPI:1245228790
Name:ELLENBERG, MAURY RUBEN (MD)
Entity Type:Individual
Prefix:MR
First Name:MAURY
Middle Name:RUBEN
Last Name:ELLENBERG
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 1:6676 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6006
Mailing Address - Country:US
Mailing Address - Phone:248-893-3220
Mailing Address - Fax:248-893-2950
Practice Address - Street 1:28455 HAGGERTY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2982
Practice Address - Country:US
Practice Address - Phone:248-893-3200
Practice Address - Fax:248-893-2950
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034191208100000X, 208VP0000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4212207Medicaid
B48639Medicare UPIN
MI4212207Medicaid