Provider Demographics
NPI:1942473335
Name:ELLSWORTH, HEATHER (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ELLSWORTH
Other - Last Name:SURTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:640 JACKSON STREET
Mailing Address - Street 2:REGIONS HOSPITAL
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101
Mailing Address - Country:US
Mailing Address - Phone:651-254-3456
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:REGIONS HOSPITAL
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52983207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine