Provider Demographics
NPI:1689622763
Name:ROYAL, ELLEN LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:LEWIS
Last Name:ROYAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 CORPORATE PARK DR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-7283
Mailing Address - Country:US
Mailing Address - Phone:334-203-1766
Mailing Address - Fax:334-203-1784
Practice Address - Street 1:2901 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-7283
Practice Address - Country:US
Practice Address - Phone:334-203-1766
Practice Address - Fax:334-203-1784
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL217632080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000044755Medicaid
AL44755OtherBLUE CROSS & BLUE SHIELD
AL000044755Medicaid