Healthcare Provider Details

I. General information

NPI: 1164694634
Provider Name (Legal Business Name): ELLEN ELMORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11149 RESEARCH BLVD SUITE 210
AUSTIN TX
78759-5279
US

IV. Provider business mailing address

11149 RESEARCH BLVD SUITE 210
AUSTIN TX
78759-5279
US

V. Phone/Fax

Practice location:
  • Phone: 512-231-1901
  • Fax: 512-231-1902
Mailing address:
  • Phone: 512-231-1901
  • Fax: 512-231-1902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8800
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6418
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP2852
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: