Provider Demographics
NPI:1962437491
Name:MODELL, ELLEN M (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:MODELL
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 1:7320 216TH ST SW
Mailing Address - Street 2:SUITE 310
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8006
Mailing Address - Country:US
Mailing Address - Phone:425-673-3800
Mailing Address - Fax:
Practice Address - Street 1:7320 216TH ST SW
Practice Address - Street 2:SUITE 310
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8006
Practice Address - Country:US
Practice Address - Phone:425-673-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA130022930OtherRR MEDICARE
WA8221814Medicaid
WA8221814Medicaid
WAGAB08243Medicare PIN