Provider Demographics
NPI:1891879268
Name:BLOOD, ELLEN R (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:R
Last Name:BLOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19420
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9420
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-788-7032
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-788-7032
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP53419Medicare UPIN
ILK13686Medicare ID - Type Unspecified