Provider Demographics
NPI:1831129220
Name:ELLIS, RICKIE WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICKIE
Middle Name:WADE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7561
Mailing Address - Fax:
Practice Address - Street 1:107 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-4933
Practice Address - Country:US
Practice Address - Phone:252-522-9800
Practice Address - Fax:252-523-9790
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2001014422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH55029Medicare UPIN