MEDICARE: DR. KENNETH K ELLIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	H9203	TX

General Provider Information

NPI Number	:	1114902228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH K ELLIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 10597
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78766-1597
Country	:	US
Telephone Number	:	512-485-5878
Fax Number	:	512-420-0397

Provider Business Practice Location Address
First Line	:	11111 RESEARCH BLVD
Second Line	:	SUITE 390
City	:	AUSTIN
State	:	TX
Zip	:	78759-5264
Country	:	US
Telephone Number	:	512-244-2273
Fax Number	:	512-671-7883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	02/14/2008

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