Basic Information
| Provider Information | |||||||||
| NPI: | 1962446757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | TRUITT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 29TH AVE N STE 202 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N STE 202 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 24148 | AL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 174400000X | 43311 | TN | N | Other Service Providers | Specialist | 207L00000X | 43311 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 009972735 | 05 | AL | MEDICAID | 009972745 | 05 | AL | MEDICAID | 08526719 | 05 | MS | MEDICAID | 3001384 | 05 | TN | MEDICAID | 7100041490 | 05 | KY | MEDICAID | 051531876 | 01 | AL | BLUE CROSS | OTHER | 051525265 | 01 | AL | BLUE CROSS | OTHER | 4169205 | 01 | TN | BCBS | OTHER | 051525270 | 01 | AL | BLUE CROSS | OTHER | 051525268 | 01 | AL | BLUE CROSS | OTHER | 009972755 | 05 | AL | MEDICAID |