Provider Demographics
NPI:1851333082
Name:ELLEDGE, WILLIAM N (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:N
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:N
Other - Last Name:ELLEDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2153 DEPT 40339
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9387
Mailing Address - Country:US
Mailing Address - Phone:706-271-0100
Mailing Address - Fax:
Practice Address - Street 1:202 CULLENS ST NW
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-9417
Practice Address - Country:US
Practice Address - Phone:360-458-7761
Practice Address - Fax:360-458-6612
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012053207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT00131OtherREGENCE
WA62142OtherL&I
WA1517200Medicaid
WAT00131OtherREGENCE
A08390Medicare UPIN