Healthcare Provider Details

I. General information

NPI: 1316955099
Provider Name (Legal Business Name): CAREY EUGENE ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/16/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MILWAUKEE AVE
LINCOLNSHIRE IL
60069-3839
US

IV. Provider business mailing address

NORTHSHORE MEDICAL GROUP 2650 RIDGE AVE. SUITE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax:
Mailing address:
  • Phone: 847-982-6710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036110022
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036-110022
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: