Healthcare Provider Details

I. General information

NPI: 1477527877
Provider Name (Legal Business Name): JOHN C ELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 NE GOODVIEW CIRCLE
LEES SUMMIT MO
64064
US

IV. Provider business mailing address

3340 NE RALPH POWELL RD SUITE B
LEES SUMMIT MO
64064-2368
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-4200
  • Fax: 816-478-0507
Mailing address:
  • Phone: 816-875-2599
  • Fax: 816-875-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR8E78
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: