Provider Demographics
NPI:1699903245
Name:ELLIMOOTTIL, CHANDY (MD)
Entity type:Individual
Prefix:
First Name:CHANDY
Middle Name:
Last Name:ELLIMOOTTIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHAD
Other - Middle Name:
Other - Last Name:ELLIMOOTTIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108
Practice Address - Country:US
Practice Address - Phone:734-936-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056933208600000X
MI4301107020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery