Basic Information
| Provider Information | |||||||||
| NPI: | 1780602037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLEMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18667 | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410180667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723617 | ||||||||
| FaxNumber: | 8595722366 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | FORT THOMAS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410751793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723618 | ||||||||
| FaxNumber: | 8595722366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01044634A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 31201 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21708778 | 05 | OH | MEDICAID | 20082410 | 05 | IN | MEDICAID | 64312010 | 05 | KY | MEDICAID |