Basic Information
| Provider Information | |||||||||
| NPI: | 1821431123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658089007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 S NATIONAL AVE STE 900 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753087 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
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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 | 2084N0400X | R1743 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 2018014545 | MO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | R1743 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | 2018014545 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 1821431123 | 05 | MO | MEDICAID |