Provider Demographics
NPI:1598127243
Name:ELLIS, MICHAEL
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 QUIVIRA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-2857
Mailing Address - Country:US
Mailing Address - Phone:913-831-7400
Mailing Address - Fax:913-831-7409
Practice Address - Street 1:8600 QUIVIRA RD STE 100
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-2857
Practice Address - Country:US
Practice Address - Phone:913-831-7400
Practice Address - Fax:913-831-7409
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022028016207W00000X, 207WX0107X
OH35138864207W00000X
KS04-46569207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0396125Medicaid