Basic Information
Provider Information | |||||||||
NPI: | 1194791343 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLINGSEN | ||||||||
FirstName: | DONALD | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 W 5TH AVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992042715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093442663 | ||||||||
FaxNumber: | 5096249179 | ||||||||
Practice Location | |||||||||
Address1: | 601 W 5TH AVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992042715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093442663 | ||||||||
FaxNumber: | 5096249179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2006 | ||||||||
LastUpdateDate: | 03/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD00030696 | WA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | E40491 | 01 | WA | ASURIS NW HEALTH | OTHER | K6401 | 01 | ID | BLUE CROSS OF ID | OTHER | 1083740 | 05 | WA |   | MEDICAID | 44492 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER | 000010002352 | 01 | ID | REGENCE BLUE SHIELD | OTHER | 3429 | 01 | WA | GROUP HEALTH NW | OTHER | 8922409 | 01 | WA | CRIME VICTIMS | OTHER |