Provider Demographics
NPI:1457383226
Name:ELLISON, RAYCINIA KIMLAYANA (MD)
Entity Type:Individual
Prefix:
First Name:RAYCINIA
Middle Name:KIMLAYANA
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RAYCINIA
Other - Middle Name:K
Other - Last Name:CREER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9411 N OAK TRFY STE LL1
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2262
Mailing Address - Country:US
Mailing Address - Phone:816-691-1655
Mailing Address - Fax:
Practice Address - Street 1:2000 NE VIVION RD STE 100
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-6100
Practice Address - Country:US
Practice Address - Phone:816-453-1314
Practice Address - Fax:816-453-3434
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018010292207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC138KROtherBCBS
NC89138KRMedicaid
NCP00196096OtherRR MEDICARE
NCP00196096OtherRR MEDICARE
NCI21018Medicare UPIN