Basic Information
| Provider Information | |||||||||
| NPI: | 1194734145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JULIUS | ||||||||
| MiddleName: | RODNEY | ||||||||
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| Credential: | MD FACOG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 STATE ST | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193624690 | ||||||||
| FaxNumber: | 2193624692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 STATE ST | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193624690 | ||||||||
| FaxNumber: | 2193624692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01052711A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000522304 | 01 | IN | ANTHEM, BCBS | OTHER | 200286860 | 05 | IN | MEDICAID |