Provider Demographics
NPI:1477528644
Name:ELLIS, ERIC R (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
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:PO BOX 440261
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0261
Mailing Address - Country:US
Mailing Address - Phone:423-698-1844
Mailing Address - Fax:423-624-2226
Practice Address - Street 1:605 GLENWOOD DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1130
Practice Address - Country:US
Practice Address - Phone:423-698-1844
Practice Address - Fax:423-624-2226
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019592174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3047073Medicaid
TNE07602Medicare UPIN
TN3047073Medicare ID - Type Unspecified
TN3047073Medicaid