=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154465276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT E ELLIS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 08/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9115 LEESGATE RD SUITE C
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40222-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-719-0782
-----------------------------------------------------
Fax | 502-719-0787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9115 LEESGATE RD SUITE C
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40222-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-719-0782
-----------------------------------------------------
Fax | 502-719-0787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROBERT E ELLIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 502-719-0782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 19194
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------