Provider Demographics
NPI:1447697743
Name:ELLERMAN, JUSTIN L (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:L
Last Name:ELLERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:575 STANTON RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2344
Practice Address - Country:US
Practice Address - Phone:251-471-7207
Practice Address - Fax:251-471-7468
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD44779208D00000X
SCMD35678208D00000X
ALMD.37491207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice