MEDICARE: DR. PAMELA I ELLSWORTH 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	208800000X	Urology Physician	150422	MA
2	2088P0231X	Pediatric Urology Physician	ME129642	FL
3	208800000X	Urology Physician	MD11894	RI
4	2088P0231X	Pediatric Urology Physician	150422	MA

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
2	31017	OTHER	RI	BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417948647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAMELA I ELLSWORTH M.D.

Provider Business Mailing Address
First Line	:	10140 CENTURION PKWY N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-0532
Country	:	US
Telephone Number	:	904-697-4127
Fax Number	:	904-697-5102

Provider Business Practice Location Address
First Line	:	13535 NEMOURS PKWY
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32827-7402
Country	:	US
Telephone Number	:	407-567-4000
Fax Number	:	407-567-5924

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

Provider Enumeration Date	:	11/05/2005
Last Update Date	:	01/13/2018

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Directions to “ DR. PAMELA I ELLSWORTH M.D.” Practice Location

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