Basic Information
| Provider Information | |||||||||
| NPI: | 1790050128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PRESBYTERIAN HEALTHCARE SERVICES - PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 CONSTITUTION AVE NE | ||||||||
| Address2: | PMG EMERGENCY MEDICINE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052912122 | ||||||||
| FaxNumber: | 5052912979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2012 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD2015-0028 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | 390200000 | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.