Provider Demographics
NPI:1972578979
Name:ELLSWORTH, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:ELLSWORTH
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 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-853-2716
Mailing Address - Fax:508-856-9025
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-853-2716
Practice Address - Fax:508-856-9025
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA380512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1150042OtherFIRST HEALTH
5635531OtherAETNA
784213OtherMVP HEALTH CARE
C05097OtherBLUE SHIELD INDEMNITY
26802OtherHEALTHY START
C05097OtherBLUE SHIELD HMO BLUE
042472266OtherONE HEALTH PLAN
9900863OtherFALLON COMMUNITY HEALTH P
AA4010OtherHARVARD PILGRIM HEALTH CA
042472266OtherHEALTHCARE VALUE MANAGEME
MA2034107Medicaid
26802OtherCHILDRENS MEDICAL SECURIT
300090862OtherRAILROAD MEDICARE
4476761OtherCIGNA HEALTH PLAN
C05097OtherBLUE CARE ELECT
C05097OtherMEDICARE B
042472266OtherPRIVATE HEALTHCARE SYSTEM
2034107OtherMEDICAID WELFARE
MAC05097Medicare ID - Type Unspecified
A38673Medicare UPIN