Healthcare Provider Details

I. General information

NPI: 1093864118
Provider Name (Legal Business Name): ANDREW N ELLINGSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 VALLEY VIEW DR SUITE 202
MOLINE IL
61265-6180
US

IV. Provider business mailing address

615 VALLEY VIEW DR SUITE 202
MOLINE IL
61265-6180
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-1072
  • Fax: 309-762-1094
Mailing address:
  • Phone: 309-762-1072
  • Fax: 309-762-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number63797-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036-117228
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number35838
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35838
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number63797-20
License Number StateWI
# 6
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-117228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: