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General NPI Number Information
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NPI Number | 1407054752
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Entity Type | Organization
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Legal Business Name | SANDRA L. ELLIS, MD, PLLC
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Dates
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Enumeration Date | 07/09/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 19034 W 10 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2401
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Country | US
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Telephone | 248-353-2600
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Fax | 248-353-1367
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Provider Business Mailing Address
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Address Line | 6632 TELEGRAPH RD STE 318
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48301-3012
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Country | US
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Telephone | 248-353-2600
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Fax | 248-353-1367
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SANDRA LYNN ELLIS
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Credential | MD
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Telephone | 248-353-2600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | SE070800
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License Number State | MI
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