Provider Demographics
NPI:1922005388
Name:ELLIS, IRA KEITH (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:KEITH
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 SUMMAR DR
Mailing Address - Street 2:DEPT 289
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3915
Mailing Address - Country:US
Mailing Address - Phone:731-423-1932
Mailing Address - Fax:731-410-0367
Practice Address - Street 1:2084 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3515
Practice Address - Country:US
Practice Address - Phone:615-673-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38294207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN34018OtherTLC
TN626001636OtherUNITED HEALTHCARE
TN4101718OtherBLUE CROSS BLUE SHIELD
TN5657408OtherCIGNA
TN3823013Medicaid
TN626001636OtherUSA MANAGED CARE
TNP00277818OtherRAILROAD MEDICARE
4124210OtherBCBS
TN626001636OtherHEALTH PARTNERS
TN166981OtherUNISON
TN3895527Medicaid
TN626001636OtherUNITED HEALTHCARE
TNP00277818OtherRAILROAD MEDICARE
TN3823013Medicare PIN