Provider Demographics
NPI:1548245731
Name:ELLIS, ROBERT VICTOR II (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VICTOR
Last Name:ELLIS
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROCKY
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6356
Mailing Address - Country:US
Mailing Address - Phone:513-585-5501
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:305 CRESCENT AVE
Practice Address - Street 2:UNIVERSITY WYOMING FAMILY PRACTICE CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-4406
Practice Address - Country:US
Practice Address - Phone:513-821-0275
Practice Address - Fax:513-821-3621
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2550547Medicaid
I28389Medicare UPIN
OHEL4154506Medicare PIN
OHP00371091Medicare PIN
OHEL4154505Medicare PIN
OH2550547Medicaid