Provider Demographics
NPI:1811057870
Name:ELLOWAY, SIMON (MD)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:ELLOWAY
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 1:155 N MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2623
Mailing Address - Country:US
Mailing Address - Phone:360-748-4461
Mailing Address - Fax:360-748-1626
Practice Address - Street 1:155 N MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2623
Practice Address - Country:US
Practice Address - Phone:360-748-4461
Practice Address - Fax:360-748-1626
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00008970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1006287Medicaid
WAL00110OtherREGENCE BLUESHIELD
WA89270OtherLABORS AND INDUSTRIES
WAL00110OtherREGENCE BLUESHIELD