Provider Demographics
NPI:1295907152
Name:AMY R ELLINGSON MD PA
Entity type:Organization
Organization Name:AMY R ELLINGSON MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-214-1100
Mailing Address - Street 1:PO BOX 1015
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-1015
Mailing Address - Country:US
Mailing Address - Phone:320-214-1100
Mailing Address - Fax:320-214-1155
Practice Address - Street 1:1037 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5005
Practice Address - Country:US
Practice Address - Phone:320-214-1100
Practice Address - Fax:320-214-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1538207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02937Medicare PIN