Provider Demographics
NPI:1275500597
Name:ELLIS, JAMES LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LEE
Last Name:ELLIS
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:PO BOX 11955
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0132
Mailing Address - Country:US
Mailing Address - Phone:731-541-5000
Mailing Address - Fax:614-210-1886
Practice Address - Street 1:620 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-541-6174
Practice Address - Fax:731-541-8008
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN163622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4102603OtherBCBS
300056938OtherRR MEDICARE
3058561OtherBCBS
TN3018989Medicaid
TN3328436Medicaid
TN3328435Medicaid
TNC46933Medicare UPIN
4102603OtherBCBS
3058561OtherBCBS
300056938OtherRR MEDICARE