Provider Demographics
NPI:1841309762
Name:ELLISON, ROBERT STANFILL (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STANFILL
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32070
Mailing Address - Street 2:614 HOWARD STREET
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28608-2070
Mailing Address - Country:US
Mailing Address - Phone:828-262-3100
Mailing Address - Fax:828-262-6262
Practice Address - Street 1:614 HOWARD STREET
Practice Address - Street 2:ASU STUDENT HEALTH SERVICE
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-262-3100
Practice Address - Fax:828-262-6262
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404395Medicaid