Provider Demographics
NPI:1609877398
Name:ELLSWORTH MEDICAL CLINIC
Entity Type:Organization
Organization Name:ELLSWORTH MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:NED
Authorized Official - Last Name:WHITMER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:785-472-3111
Mailing Address - Street 1:1602 N AYLWARD AVE
Mailing Address - Street 2:PO BOX 103
Mailing Address - City:ELLSWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:67439-2541
Mailing Address - Country:US
Mailing Address - Phone:785-472-3111
Mailing Address - Fax:785-472-5731
Practice Address - Street 1:1602 N AYLWARD AVE
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:KS
Practice Address - Zip Code:67439-2541
Practice Address - Country:US
Practice Address - Phone:785-472-3111
Practice Address - Fax:785-472-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-18778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS016513OtherBCBS
KS016513OtherBCBS