Provider Demographics
NPI:1942342936
Name:ELLIS, RONALD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1229 E SEMINOLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-2064
Practice Address - Fax:417-820-8716
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G80207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO82676OtherAR BLUE SHIELD #
AR122768001Medicaid
MO202444436Medicaid
MO202444444Medicaid
MO202444436Medicaid
MO82676OtherAR BLUE SHIELD #
MO202444444Medicaid