Provider Demographics
NPI:1871064568
Name:ELLIS MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:ELLIS MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-520-5020
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:ELLIS
Mailing Address - State:KS
Mailing Address - Zip Code:67637-0174
Mailing Address - Country:US
Mailing Address - Phone:785-259-4261
Mailing Address - Fax:785-520-5025
Practice Address - Street 1:814 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ELLIS
Practice Address - State:KS
Practice Address - Zip Code:67637-2215
Practice Address - Country:US
Practice Address - Phone:785-520-5020
Practice Address - Fax:785-520-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty