Healthcare Provider Details

I. General information

NPI: 1508848102
Provider Name (Legal Business Name): WAYNE M. ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD UH 3005
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130 PROVIDER ENROLLMENT
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2167
  • Fax: 317-944-2305
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01048446
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01048446A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01048446A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: