Basic Information
| Provider Information | |||||||||
| NPI: | 1518919406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | CENTANNI | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 AIRPORT BLVD STE D143 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366086701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2512663361 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 N SECTION ST | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365322649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516603470 | ||||||||
| FaxNumber: | 2516603471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO850 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810005825 | 05 | WV | MEDICAID | DO850 | 01 | AL | MEDICAL LICENSE | OTHER | 51119080 | 01 | AL | BC | OTHER |