=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467941633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN LEE BERRY FRAZIER DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2018
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3905 WELLNESS WAY
-----------------------------------------------------
City | BOZEMAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59718-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-898-1300
-----------------------------------------------------
Fax | 406-898-1309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1680
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25717-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-697-1396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3745
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------