Provider Demographics
NPI:1497072631
Name:ELLIS, TINA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:ELLIS
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 1:1 VIRGINIA AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4427
Mailing Address - Country:US
Mailing Address - Phone:401-490-0927
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:DAVOL 129
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14603207L00000X
PAMT197112390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology