Basic Information
| Provider Information | |||||||||
| NPI: | 1669567434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2127 E BASELINE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852831537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808977070 | ||||||||
| FaxNumber: | 4808972597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2127 E BASELINE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852831537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808977070 | ||||||||
| FaxNumber: | 4808972597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD12426 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080055004 | 01 | AZ | RAILROAD MEDICARE | OTHER | 214510 | 05 | AZ | MEDICAID | AZ0006680 | 01 | BLUE CROSS BLUE SHIELD | OTHER |