Provider Demographics
NPI:1245234988
Name:MIDDENDORF, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:STE. 160
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5368
Mailing Address - Country:US
Mailing Address - Phone:618-235-0460
Mailing Address - Fax:618-235-1464
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:STE. 160
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5368
Practice Address - Country:US
Practice Address - Phone:618-235-0460
Practice Address - Fax:618-235-1464
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108143Medicaid
IL1245234988Medicaid
ILK01455Medicare PIN
IL036108143Medicaid
ILIL3374012Medicare PIN