MEDICARE: DR. ELLEN D DILLAVOU 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	2086S0129X	Vascular Surgery Physician	2015-01778	NC
2	208600000X	Surgery Physician	2015-01778	NC
3	2086S0129X	Vascular Surgery Physician	MD066225L	PA

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	:	1932172442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN D DILLAVOU MD

Provider Business Mailing Address
First Line	:	PO BOX 63362
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28263-3362
Country	:	US
Telephone Number	:	800-782-6945
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 NEW BERN AVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-1231
Country	:	US
Telephone Number	:	919-350-8000
Fax Number	:

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	12/04/2025

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