MEDICARE: DR. ELLEN J O'CONNELL MD

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	207P00000X	Emergency Medicine Physician	L9831	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8C0848	OTHER	TX	BCBS
2	P00399314	OTHER	TX	RAILROAD

General Provider Information

NPI Number	:	1063440121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN J O'CONNELL MD

Provider Business Mailing Address
First Line	:	4034 RAWLINS ST APT 106
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-5632
Country	:	US
Telephone Number	:	214-252-0490
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 W MAIN ST
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75057-3629
Country	:	US
Telephone Number	:	972-420-1576
Fax Number	:

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	10/04/2007

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