Provider Demographics
NPI:1316976855
Name:ELLIS, ROBERT M (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
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 3395
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47732-3395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1373 E SR 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250
Practice Address - Country:US
Practice Address - Phone:812-801-0865
Practice Address - Fax:812-801-0775
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4364752OtherAETNA
KY64759715Medicaid
080100605OtherMEDICARE RAILROAD
IN100148650AMedicaid
IN414646POtherSIHO
IN000000042192OtherANTHEM BCBS
IN42192OtherANTHEM
4364752OtherAETNA
KY64759715Medicaid
IN412840EMedicare ID - Type Unspecified