Provider Demographics
NPI:1376511931
Name:ELLIS, EDWARD STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:STEPHEN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 PARLIAMENT DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-7212
Mailing Address - Country:US
Mailing Address - Phone:865-690-2759
Mailing Address - Fax:
Practice Address - Street 1:110 DEER XING
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2133
Practice Address - Country:US
Practice Address - Phone:423-884-6958
Practice Address - Fax:423-884-6959
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012142207R00000X, 2083P0500X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND68762Medicare UPIN