Provider Demographics
NPI:1821046780
Name:ELLIS, B KEITH (M D)
Entity Type:Individual
Prefix:
First Name:B
Middle Name:KEITH
Last Name:ELLIS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16651 SOUTHWEST FWY
Mailing Address - Street 2:MOB 1, SUITE 400
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2345
Mailing Address - Country:US
Mailing Address - Phone:713-776-9500
Mailing Address - Fax:713-400-7220
Practice Address - Street 1:16651 SOUTHWEST FWY
Practice Address - Street 2:MOB 1, SUITE 400
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2345
Practice Address - Country:US
Practice Address - Phone:713-776-9500
Practice Address - Fax:713-400-7220
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7368207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166000306Medicaid
TX166000303Medicaid
TX166000304Medicaid
TX166000305Medicaid
TX1821046780OtherBLUE CROSS BLUE SHIELD
TXP01301854OtherRR MEDICARE
TX8DJ181OtherBCBS
P01086528OtherRR MEDICARE
TX331817ZSWDMedicare PIN
TX331817ZSVEMedicare PIN
TX331817YMCQMedicare PIN
TXP00144845Medicare PIN
TX166000304Medicaid
TX331817YQ64Medicare PIN
TX8DJ181OtherBCBS
TX166000303Medicaid