Basic Information
| Provider Information | |||||||||
| NPI: | 1356432009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEROY | ||||||||
| FirstName: | ELLIS | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014298000 | ||||||||
| FaxNumber: | 8014298150 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 E 100 N | ||||||||
| Address2: | # 1 | ||||||||
| City: | PAYSON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014654813 | ||||||||
| FaxNumber: | 8014657207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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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 | 207R00000X | 159570-1205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 22811 | 01 | UT | PEHP | OTHER | 36374 | 01 | UT | DMBA | OTHER | 870281028EWJ | 01 | UT | EMIA | OTHER | 110090648 | 01 | UT | PALMETTO | OTHER | 87028108000 | 05 | UT | MEDICAID | 04-00323 | 01 | UT | UTAH HEALTHCARE | OTHER | 10700660401 | 01 | UT | IHC | OTHER | QMXAF0342 | 01 | UT | ALTIUS | OTHER |