Provider Demographics
NPI:1346375235
Name:ELLISON, EDWARD D (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:D
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:980 IRONWOOD DR W
Mailing Address - Street 2:STE 104
Mailing Address - City:COEUR D' ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-667-0621
Mailing Address - Fax:208-664-1709
Practice Address - Street 1:980 IRONWOOD DR W
Practice Address - Street 2:STE 104
Practice Address - City:COEUR D' ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-667-0621
Practice Address - Fax:208-664-1709
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-05-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM-8020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805898101Medicaid
IDH19647Medicare UPIN
ID1144239Medicare ID - Type Unspecified