Healthcare Provider Details

I. General information

NPI: 1841309762
Provider Name (Legal Business Name): ROBERT STANFILL ELLISON MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 HOWARD STREET ASU STUDENT HEALTH SERVICE
BOONE NC
28607
US

IV. Provider business mailing address

PO BOX 32070 614 HOWARD STREET
BOONE NC
28608-2070
US

V. Phone/Fax

Practice location:
  • Phone: 828-262-3100
  • Fax: 828-262-6262
Mailing address:
  • Phone: 828-262-3100
  • Fax: 828-262-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number28181
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: