Provider Demographics
NPI:1427006816
Name:ELLIS, ROBERT ELLSWORTH (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLSWORTH
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 1:9115 LEESGATE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5003
Mailing Address - Country:US
Mailing Address - Phone:502-719-0782
Mailing Address - Fax:502-719-0787
Practice Address - Street 1:9115 LEESGATE RD
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5003
Practice Address - Country:US
Practice Address - Phone:502-719-0782
Practice Address - Fax:502-719-0787
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1058692OtherPASSPORT
KY110000678OtherMEDICARE RR
KY64191943Medicaid
KY000000047003OtherANTHEM
KY2433985000OtherPASSPORT ADVANTAGE
KY000000047003OtherANTHEM
KY2433985000OtherPASSPORT ADVANTAGE