Provider Demographics
NPI:1942288295
Name:ELLIS, KATHRYN R (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:171 MAIN ST STE 203B
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-1187
Mailing Address - Country:US
Mailing Address - Phone:508-881-3029
Mailing Address - Fax:508-881-1752
Practice Address - Street 1:730 MAIN ST
Practice Address - Street 2:1A
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1612
Practice Address - Country:US
Practice Address - Phone:508-376-2515
Practice Address - Fax:508-376-9932
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA160327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3204723Medicaid
MAA31189Medicare ID - Type Unspecified
MAH18308Medicare UPIN