MEDICARE: DARYL ELLIS 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	207Q00000X	Family Medicine Physician	00018084	AL

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	:	1467468355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARYL ELLIS MD

Provider Business Mailing Address
First Line	:	5009 RIVERCHASE DR
Second Line	:	SUITE 500
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-7490
Country	:	US
Telephone Number	:	334-448-9505
Fax Number	:	334-448-9575

Provider Business Practice Location Address
First Line	:	5009 RIVER CHASE DR
Second Line	:	SUITE 500
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-7425
Country	:	US
Telephone Number	:	334-448-9505
Fax Number	:	334-448-9575

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	11/21/2012

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