Provider Demographics
NPI:1578537098
Name:ELLIS, KEVIN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
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 1:2827 WILLOWICK TRL SE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON COVE
Mailing Address - State:AL
Mailing Address - Zip Code:35763-8689
Mailing Address - Country:US
Mailing Address - Phone:265-564-9923
Mailing Address - Fax:
Practice Address - Street 1:1963 MEMORIAL PKWY SW
Practice Address - Street 2:SUITE 5
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5036
Practice Address - Country:US
Practice Address - Phone:256-265-2464
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25009208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics