Provider Demographics
NPI:1477527877
Name:ELLIS, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
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 1:3340 NE RALPH POWELL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2368
Mailing Address - Country:US
Mailing Address - Phone:816-875-2599
Mailing Address - Fax:816-875-2598
Practice Address - Street 1:4880 NE GOODVIEW CIRCLE
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064
Practice Address - Country:US
Practice Address - Phone:816-478-4200
Practice Address - Fax:816-478-0507
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8E78174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4001449OtherAETNA
MO11540041OtherBCBS OF KC
MO1008021OtherUHC
MO9852OtherBNDD
MO204510882OtherCHAMPUS
MO204510882OtherCHAMPUS
MO1008021OtherUHC
MOBE7484671OtherDEA
MOW445437Medicare ID - Type UnspecifiedMO MEDICARE