Basic Information
| Provider Information | |||||||||
| NPI: | 1194765560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718924 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/03/2014 | ||||||||
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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 | 207Y00000X | 26121-020 | WI | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1023 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 30578500 | 05 | WI | MEDICAID |