=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134193816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN M ALTENBURG MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2006
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 N WICKHAM RD STE 132B
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-425-6900
-----------------------------------------------------
Fax | 321-802-5599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1344 S APOLLO BLVD STE 406
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-3185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-727-2990
-----------------------------------------------------
Fax | 321-724-0455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME0073871
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------