Healthcare Provider Details

I. General information

NPI: 1134292766
Provider Name (Legal Business Name): RUSSELL L ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 16TH AVE SE
DECATUR AL
35601-3595
US

IV. Provider business mailing address

1107 14TH AVE SE STE 300
DECATUR AL
35601-3368
US

V. Phone/Fax

Practice location:
  • Phone: 256-350-0362
  • Fax:
Mailing address:
  • Phone: 256-350-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number00022020
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: