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General NPI Number Information
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NPI Number | 1174637599
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Entity Type | Organization
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Legal Business Name | MICHAEL R ELLEN MD PS
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 128 LILLY RD NE SUITE 205
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City | OLYMPIA
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State | WA
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Zip | 98506-5029
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Country | US
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Telephone | 360-754-3380
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Fax |
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Provider Business Mailing Address
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Address Line | 128 LILLY RD NE SUITE 205
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City | OLYMPIA
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State | WA
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Zip | 98506-5029
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Country | US
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Telephone | 360-754-3380
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL R ELLEN
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Credential | MD
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Telephone | 360-754-3380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | MD00026526
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License Number State | WA
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