Provider Demographics
NPI:1407054752
Name:SANDRA L. ELLIS, MD, PLLC
Entity type:Organization
Organization Name:SANDRA L. ELLIS, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-353-2600
Mailing Address - Street 1:6632 TELEGRAPH RD
Mailing Address - Street 2:STE 318
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3012
Mailing Address - Country:US
Mailing Address - Phone:248-353-2600
Mailing Address - Fax:248-353-1367
Practice Address - Street 1:19034 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2401
Practice Address - Country:US
Practice Address - Phone:248-353-2600
Practice Address - Fax:248-353-1367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISE070800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104077793Medicaid
MI104077793Medicaid
MI104077793Medicaid
MI=========OtherTAX ID