Basic Information
| Provider Information | |||||||||
| NPI: | 1891726527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAGSTEN | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | VIRGINIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 970 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356530970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563321631 | ||||||||
| FaxNumber: | 2563324600 | ||||||||
| Practice Location | |||||||||
| Address1: | 68 MARCO DRIVE SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356030000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564322007 | ||||||||
| FaxNumber: | 2564322010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 00020153 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 630102047 | 05 | AL | MEDICAID | 51525668 | 01 | BLUE CROSS BLUE SHIELD | OTHER |