Provider Demographics
NPI:1316110208
Name:ELLIS, ETHAN R (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:R
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 1:2121 E HARMONY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:STE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053902207RC0001X, 207RC0000X, 207R00000X
NE27958207RC0001X
MA235720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87529351Medicaid
CO359522YLB8Medicare PIN