Provider Demographics
NPI:1326072232
Name:GEFROH ELLISON, STEFANIE S (MD)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:S
Last Name:GEFROH ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:S
Other - Last Name:GHAZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-8000
Mailing Address - Fax:701-364-8078
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9688207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13112Medicaid
NDDA9011041661OtherPREFERRED ONE #
ND0704093OtherMEDICA #
ND34894OtherLHS #
ND24613OtherNDBS #
ND856410800Medicaid
ND0704094OtherMEDICA #
ND2155911OtherAMERICA'S PPO/ARAZ #
ND137094OtherUCARE #
ND850S5GEOtherMNBS #
NDHP44194OtherHEALTHPARTNERS #
ND34894OtherLHS #
NDN714398Medicare Oscar/Certification
NDDA9011041661OtherPREFERRED ONE #
ND137094OtherUCARE #
ND0704093OtherMEDICA #
ND856410800Medicaid
ND850S5GEOtherMNBS #
ND24613Medicare ID - Type UnspecifiedND MEDICARE #
NDN711328Medicare PIN