Provider Demographics
NPI:1962446757
Name:ELLIS, TRUITT C (MD)
Entity Type:Individual
Prefix:
First Name:TRUITT
Middle Name:C
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 1:110 29TH AVE N STE 202
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1448
Mailing Address - Country:US
Mailing Address - Phone:615-327-4304
Mailing Address - Fax:615-327-7940
Practice Address - Street 1:110 29TH AVE N STE 202
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1448
Practice Address - Country:US
Practice Address - Phone:615-327-4304
Practice Address - Fax:615-327-7940
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24148207L00000X
TN43311174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009972735Medicaid
AL009972745Medicaid
MS08526719Medicaid
TN3001384Medicaid
KY7100041490Medicaid
AL051531876OtherBLUE CROSS
AL051525265OtherBLUE CROSS
TN4169205OtherBCBS
AL051525270OtherBLUE CROSS
AL051525268OtherBLUE CROSS
AL009972755Medicaid
AL051525265OtherBLUE CROSS
AL051525268OtherBLUE CROSS
TNP00479011Medicare PIN
AL051525265Medicare PIN