Provider Demographics
NPI:1245418110
Name:RODNEY L. ELLIS, MD, PC
Entity Type:Organization
Organization Name:RODNEY L. ELLIS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-552-3953
Mailing Address - Street 1:9811 GREENBELT RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2215
Mailing Address - Country:US
Mailing Address - Phone:301-552-3953
Mailing Address - Fax:
Practice Address - Street 1:9811 GREENBELT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2215
Practice Address - Country:US
Practice Address - Phone:301-552-3953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0021326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC62776Medicare UPIN
MDG01512R01Medicare PIN