Basic Information
| Provider Information | |||||||||
| NPI: | 1356437875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLERBECK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | KANSAS UNIVERSITY PHYSICIANS INC | ||||||||
| Address2: | 3901 RAINBOW BLVD, 4070 DELP, MAIL STOP 4017 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135882500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD DELP 6040 MS 1020 | ||||||||
| Address2: | KANSAS UNIVERSITY PHYSICIANS INC | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135883974 | ||||||||
| FaxNumber: | 9135886055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
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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 | 207R00000X | 04-20890 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11549075 | 01 | MO | BCBS KC | OTHER | 625720 | 01 | KS | FIRSTGUARD | OTHER | 100181080A | 05 | KS | MEDICAID | 202115010 | 05 | MO | MEDICAID |