MEDICARE: DR. ADAM WESLEY ELLIS M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	40994	KY

General Provider Information

NPI Number	:	1003918731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAM WESLEY ELLIS M.D

Provider Business Mailing Address
First Line	:	1623 NASHVILLE ST
Second Line	:	STE 106
City	:	RUSSELLVILLE
State	:	KY
Zip	:	42276-8889
Country	:	US
Telephone Number	:	270-726-8090
Fax Number	:	270-726-9008

Provider Business Practice Location Address
First Line	:	1623 NASHVILLE ST
Second Line	:	STE 106
City	:	RUSSELLVILLE
State	:	KY
Zip	:	42276-8889
Country	:	US
Telephone Number	:	270-726-8090
Fax Number	:	270-726-9008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	08/02/2023

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