Basic Information
| Provider Information | |||||||||
| NPI: | 1861419491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1289 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336011289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444300 | ||||||||
| FaxNumber: | 8138441909 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 MORRISON RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444300 | ||||||||
| FaxNumber: | 8138441909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME125071 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 383454949 | 01 | MI | TAX ID | OTHER | 104077793 | 05 | MI | MEDICAID |