Provider Demographics
NPI:1598791535
Name:ELLIS, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
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:PO BOX 7695
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-0026
Mailing Address - Country:US
Mailing Address - Phone:662-328-2476
Mailing Address - Fax:662-327-4605
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS131702085R0202X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112542Medicaid
MS300124842OtherRAIL ROAD MEDICARE
MS300000989Medicare ID - Type Unspecified
F46521Medicare UPIN