Provider Demographics
NPI:1699938688
Name:ELLIS, MADELINE R (MD)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 WINDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2247
Mailing Address - Country:US
Mailing Address - Phone:985-237-9149
Mailing Address - Fax:615-535-0230
Practice Address - Street 1:214 E MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-3031
Practice Address - Country:US
Practice Address - Phone:615-686-2346
Practice Address - Fax:615-535-0230
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51141208000000X, 208000000X
MO2013038951208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ005652Medicaid