MEDICARE: HENRY M ELLETT MD

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	0101044338	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356337059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HENRY M ELLETT MD

Provider Business Mailing Address
First Line	:	2369 STAPLES MILL RD
Second Line	:	SUITE 200
City	:	RICHMOND
State	:	VA
Zip	:	23230-2918
Country	:	US
Telephone Number	:	804-285-4465
Fax Number	:	804-285-8332

Provider Business Practice Location Address
First Line	:	201 WADSWORTH DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23236-4510
Country	:	US
Telephone Number	:	804-285-8206
Fax Number	:	804-320-3102

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	01/28/2010

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