Provider Demographics
NPI:1275515314
Name:ELLIS, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 W 110TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2144
Mailing Address - Country:US
Mailing Address - Phone:913-428-2900
Mailing Address - Fax:913-428-2951
Practice Address - Street 1:19600 E 39TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2301
Practice Address - Country:US
Practice Address - Phone:913-428-2900
Practice Address - Fax:913-428-2951
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5J54207L00000X
KS04-21076207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100192350CMedicaid
MO202168845Medicaid
MOA76731Medicare UPIN
MO0135473Medicare ID - Type Unspecified