Provider Demographics
NPI:1194765560
Name:ELLISON, WARREN R (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:R
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E RACINE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8924
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8924
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26121-020207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023OtherDEAN HEALTH INSURANCE
WI30578500Medicaid
WI040005207Medicare PIN
WI003954340Medicare PIN
WIK400111020Medicare PIN
B26620Medicare UPIN