Provider Demographics
NPI:1437114246
Name:ELLEDGE, PHILIP B (DMD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:B
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 PANSY ST SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3803
Mailing Address - Country:US
Mailing Address - Phone:256-534-5028
Mailing Address - Fax:256-534-5073
Practice Address - Street 1:2314 PANSY ST SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3803
Practice Address - Country:US
Practice Address - Phone:256-534-5028
Practice Address - Fax:256-534-5073
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5313C204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U57382Medicare UPIN