Provider Demographics
NPI:1508021171
Name:ELLIS, MARCO FREDRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:FREDRICK
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 1:259 E ERIE ST STE 20-2060
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2987
Mailing Address - Country:US
Mailing Address - Phone:312-695-6022
Mailing Address - Fax:312-695-5672
Practice Address - Street 1:259 E ERIE ST STE 20-2060
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2987
Practice Address - Country:US
Practice Address - Phone:312-695-6022
Practice Address - Fax:312-695-5672
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121419208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
12576013OtherCAQH