Basic Information
| Provider Information | |||||||||
| NPI: | 1992790786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618036002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173268630 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1002 MEDICAL CENTER DR | ||||||||
| Address2: | FAMILY MEDICINE | ||||||||
| City: | MONTICELLO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618562116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177622518 | ||||||||
| FaxNumber: | 2177625261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2005 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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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 | 207Q00000X | 036-081822 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.