Healthcare Provider Details

I. General information

NPI: 1881006435
Provider Name (Legal Business Name): ANDREW JAMES ELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5643
  • Fax: 314-268-4019
Mailing address:
  • Phone: 314-577-5643
  • Fax: 314-268-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01078376
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2018012696
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: