Provider Demographics
NPI:1801847249
Name:BLANK, ELLEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:L
Last Name:BLANK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC GASTROENTEROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-3690
Mailing Address - Fax:414-266-3676
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC GASTROENTEROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3690
Practice Address - Fax:414-266-3676
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI222932080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801847249Medicaid
008006261QOtherHUMANA
WI0025 73-601Medicare PIN
B51590Medicare UPIN
WI680860553Medicare PIN