Provider Demographics
NPI:1679575328
Name:ELLISON, LEONARD EUGENE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:EUGENE
Last Name:ELLISON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301068024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679575328Medicaid
MI1106353112OtherBCBS
MIMI2371001Medicare PIN
MIP09030001Medicare PIN
MI1106353112OtherBCBS