Provider Demographics
NPI:1184624819
Name:ELLENBY, MARTIN IRA (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:IRA
Last Name:ELLENBY
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 84992
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-4992
Mailing Address - Country:US
Mailing Address - Phone:918-710-3710
Mailing Address - Fax:918-770-0058
Practice Address - Street 1:10258 SOUTHWEST HWY STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1361
Practice Address - Country:US
Practice Address - Phone:708-346-9533
Practice Address - Fax:708-499-4312
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077308208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077308Medicaid
IN200123470BMedicaid
IL770000769Medicare PIN
ILE83649Medicare UPIN
IL036077308Medicaid
IL770002423Medicare PIN
IL366300Medicare PIN