Provider Demographics
NPI:1417032160
Name:ELLINGSON, AMY RILLO (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RILLO
Last Name:ELLINGSON
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 1:1605 COUNTRY CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-2176
Mailing Address - Country:US
Mailing Address - Phone:320-231-9833
Mailing Address - Fax:
Practice Address - Street 1:1037 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5005
Practice Address - Country:US
Practice Address - Phone:320-214-1100
Practice Address - Fax:320-214-1155
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34585207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G26524Medicare UPIN