Basic Information
| Provider Information | |||||||||
| NPI: | 1922005388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | IRA | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 294 SUMMAR DR | ||||||||
| Address2: | DEPT 289 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314231932 | ||||||||
| FaxNumber: | 7314100367 | ||||||||
| Practice Location | |||||||||
| Address1: | 2084 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MILAN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383583515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156736737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 38294 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4101718 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 5657408 | 01 | TN | CIGNA | OTHER | 4124210 | 01 | BCBS | OTHER | 626001636 | 01 | TN | HEALTH PARTNERS | OTHER | 166981 | 01 | TN | UNISON | OTHER | 34018 | 01 | TN | TLC | OTHER | 626001636 | 01 | TN | UNITED HEALTHCARE | OTHER | 3823013 | 05 | TN | MEDICAID | 626001636 | 01 | TN | USA MANAGED CARE | OTHER | P00277818 | 01 | TN | RAILROAD MEDICARE | OTHER | 3895527 | 05 | TN | MEDICAID |