Basic Information
| Provider Information | |||||||||
| NPI: | 1164602611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | EZRA | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3293 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176149863 | ||||||||
| FaxNumber: | 8448760873 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702191136 | ||||||||
| FaxNumber: | 7702196204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | M-10161 | ID | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 2007-00176 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 70094 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000010167581 | 01 | ID | REGENCE BLUESHIELD OF IDAHO | OTHER | 77342 | 01 | ID | BLUECROSS OF IDAHO | OTHER | 808087600 | 05 | ID | MEDICAID |