Provider Demographics
NPI:1346330669
Name:ENNIS, ELIZABETH D (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:D
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3686 GRANDVIEW PKWY
Mailing Address - Street 2:STE 810
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-3408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 MONTCLAIR RD
Practice Address - Street 2:SUITE 317
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-1920
Practice Address - Country:US
Practice Address - Phone:205-592-5135
Practice Address - Fax:205-592-5694
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL15220207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000022952Medicaid
AL000022953Medicaid
AL000022952Medicaid
AL22953Medicare ID - Type UnspecifiedMED ED MC #
AL000022953Medicaid