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General NPI Number Information
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NPI Number | 1922005388
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Entity Type | Individual
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Provider Name | IRA KEITH ELLIS MD
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Gender | Male
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 01/10/2024
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Provider Practice Location Address
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Address Line | 2084 W MAIN ST
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City | MILAN
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State | TN
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Zip | 38358-3515
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Country | US
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Telephone | 615-673-6737
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Fax |
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Provider Business Mailing Address
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Address Line | 294 SUMMAR DR DEPT 289
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City | JACKSON
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State | TN
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Zip | 38301-3915
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Country | US
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Telephone | 731-423-1932
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Fax | 731-410-0367
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 38294
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | 38294
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License Number State | TN
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