Provider Demographics
NPI:1407828486
Name:ELLIS, VICKI (MD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:
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 1:11116 MEDICAL CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:240-313-9580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD65453207Q00000X
PAMD431001207Q00000X
SC19454207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD451601000Medicaid
PA101931175Medicaid
MD304010100Medicaid
MDP00442458OtherRAILROAD
MD451601000Medicaid
MD304010100Medicaid