Provider Demographics
NPI:1518961259
Name:ELLIS, MICHAEL SYDNEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SYDNEY
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 1:1415 TULANE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2600
Mailing Address - Country:US
Mailing Address - Phone:504-988-5451
Mailing Address - Fax:504-988-5948
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-5451
Practice Address - Fax:504-988-5948
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010221174400000X
LAMD.010221207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1518961259Medicaid
MS09737205Medicaid
LA1101133Medicaid
AL1518961259Medicaid
MS09737205Medicaid
P00480242Medicare PIN
LA1101133Medicaid