Provider Demographics
NPI:1609821537
Name:LEONARD ELLISON JR MD PC
Entity Type:Organization
Organization Name:LEONARD ELLISON JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:248-552-9500
Mailing Address - Street 1:17330 NORTHLAND PARK CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4318
Mailing Address - Country:US
Mailing Address - Phone:248-552-9500
Mailing Address - Fax:248-552-8144
Practice Address - Street 1:17330 NORTHLAND PARK CT
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4318
Practice Address - Country:US
Practice Address - Phone:248-552-9500
Practice Address - Fax:248-552-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500F382740OtherBCBS GROUP
MI110F312710OtherBCBS
MI4709307Medicaid
MIA76736Medicare UPIN
MI0P09030Medicare PIN