Provider Demographics
NPI:1316955099
Name:ELLIS, CAREY EUGENE (MD)
Entity type:Individual
Prefix:
First Name:CAREY
Middle Name:EUGENE
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:NORTHSHORE MEDICAL GROUP
Mailing Address - Street 2:2650 RIDGE AVE. SUITE 1223
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-982-6710
Mailing Address - Fax:
Practice Address - Street 1:920 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3839
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110022207Q00000X
IL036-110022207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36110022Medicaid
ILH95995Medicare UPIN