Provider Demographics
NPI:1205053865
Name:ELLIS, WENDY DREW (MD)
Entity type:Individual
Prefix:DR
First Name:WENDY
Middle Name:DREW
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:DREW
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:210 25TH AVE N STE 602
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1631
Mailing Address - Country:US
Mailing Address - Phone:615-312-0600
Mailing Address - Fax:615-320-3259
Practice Address - Street 1:210 25TH AVE N STE 602
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1631
Practice Address - Country:US
Practice Address - Phone:615-312-0600
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00612342085P0229X, 2085R0202X
TN471252085R0202X
TNMD471252085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524205Medicaid