Provider Demographics
NPI:1376580563
Name:ELLIS, GAIL L (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 TOZER ROAD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-927-7727
Mailing Address - Fax:978-927-4598
Practice Address - Street 1:30 TOZER ROAD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915
Practice Address - Country:US
Practice Address - Phone:978-927-7727
Practice Address - Fax:978-927-4598
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA155239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA28867Medicare UPIN