Provider Demographics
NPI:1467468355
Name:ELLIS, DARYL (MD)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:ELLIS
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 1:5009 RIVERCHASE DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-7490
Mailing Address - Country:US
Mailing Address - Phone:334-448-9505
Mailing Address - Fax:334-448-9575
Practice Address - Street 1:5009 RIVER CHASE DR
Practice Address - Street 2:SUITE 500
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7425
Practice Address - Country:US
Practice Address - Phone:334-448-9505
Practice Address - Fax:334-448-9575
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00018084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009997735Medicaid
ALF87185Medicare UPIN
AL009997735Medicaid