Provider Demographics
NPI:1952364150
Name:ELLIS, ELAINE M (MD)
Entity Type:Individual
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First Name:ELAINE
Middle Name:M
Last Name:ELLIS
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Gender:F
Credentials:MD
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Mailing Address - Street 1:4722 N 24TH ST
Mailing Address - Street 2:STE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4800
Mailing Address - Country:US
Mailing Address - Phone:602-256-4628
Mailing Address - Fax:602-957-9438
Practice Address - Street 1:10210 N 92ND ST
Practice Address - Street 2:SUITE 207
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4509
Practice Address - Country:US
Practice Address - Phone:480-661-1332
Practice Address - Fax:480-661-1364
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2010-08-25
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Provider Licenses
StateLicense IDTaxonomies
AZ339382080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ953142Medicaid
D63888Medicare UPIN