Basic Information
| Provider Information | |||||||||
| NPI: | 1881988582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880328 | ||||||||
| FaxNumber: | 5025880326 | ||||||||
| Practice Location | |||||||||
| Address1: | ULP COLORECTAL SURGERY | ||||||||
| Address2: | 401 EAST CHESTNUT STREET, #710 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025838303 | ||||||||
| FaxNumber: | 5025889506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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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 | 390200000X | 173420 | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208C00000X | TP364 | KY | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.