Provider Demographics
NPI:1386681310
Name:ELLIS, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:7557B DANNAHER DR STE 225
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3568
Mailing Address - Country:US
Mailing Address - Phone:865-859-7330
Mailing Address - Fax:865-859-7339
Practice Address - Street 1:7557B DANNAHER DR STE 225
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3568
Practice Address - Country:US
Practice Address - Phone:865-859-7330
Practice Address - Fax:865-859-7339
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD39944207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3332524Medicaid
TN3332524Medicaid
TNI38776Medicare UPIN
TN3332524Medicare PIN