MEDICARE: DR. DALE ALICIA ELLISON 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	207ZP0213X	Pediatric Pathology Physician	E2477	AR

General Provider Information

NPI Number	:	1407808611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE ALICIA ELLISON MD

Provider Business Mailing Address
First Line	:	800 MARSHALL ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-3510
Country	:	US
Telephone Number	:	501-364-4201
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 MARSHALL ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-3510
Country	:	US
Telephone Number	:	501-364-4201
Fax Number	:

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/08/2007

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