Basic Information
Provider Information | |||||||||
NPI: | 1700855012 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELLENBOLT | ||||||||
FirstName: | DARREN | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | N17 W24100 RIVERWOOD DR. | ||||||||
Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC. | ||||||||
City: | WAUKESHA | ||||||||
State: | WI | ||||||||
PostalCode: | 531881177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2629284100 | ||||||||
FaxNumber: | 2629285835 | ||||||||
Practice Location | |||||||||
Address1: | 240 MAPLE AVE. | ||||||||
Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC. | ||||||||
City: | MUKWONAGO | ||||||||
State: | WI | ||||||||
PostalCode: | 531498475 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2629281900 | ||||||||
FaxNumber: | 2623631949 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2006 | ||||||||
LastUpdateDate: | 11/02/2011 | ||||||||
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 | 207Q00000X | 47860 | WI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 34847400 | 05 | WI |   | MEDICAID |