Basic Information
| Provider Information | |||||||||
| NPI: | 1679688774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIS-METZ | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 3 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146476326 | ||||||||
| FaxNumber: | 4146718860 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530663994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625692300 | ||||||||
| FaxNumber: | 2625692266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 29428-020 | WI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | BE1575147 | 01 | DEA NUMBER | OTHER | 31706000 | 05 | WI | MEDICAID |