Healthcare Provider Details

I. General information

NPI: 1346330669
Provider Name (Legal Business Name): ELIZABETH D ENNIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 MONTCLAIR RD SUITE 317
BIRMINGHAM AL
35213-1920
US

IV. Provider business mailing address

3686 GRANDVIEW PKWY STE 810
BIRMINGHAM AL
35243-3408
US

V. Phone/Fax

Practice location:
  • Phone: 205-592-5135
  • Fax: 205-592-5694
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number15220
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: