Provider Demographics
NPI:1184736514
Name:ELLERKMANN, RICHARD M (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:ELLERKMANN
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 824173
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1734 YORK ROAD
Practice Address - Street 2:LUTHERVILLE PERSONAL PHYSICIANS
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-252-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053101207VF0040X
MDD53101207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD102600300Medicaid
MDKJ43GY/68621301OtherCAREFIRST MARYLAND
MDKJ43GY/68621301OtherCAREFIRST MD GBMC
MDS1400001OtherCAREFIRST REGIONAL GBMC
MDS140/0001OtherCAREFIRST REGIONAL GBMC
MDX961 0014OtherCAREFIRST BLUE CHOICE
MD165L 188758YXTOtherMEDICARE
MDKJ43GY/68621301OtherCAREFIRST MD GBMC
MD160042932Medicare PIN
MDS1400001OtherCAREFIRST REGIONAL GBMC