Provider Demographics
NPI:1174573737
Name:ELLENBERGER, TRUDIE JANE (DO)
Entity type:Individual
Prefix:
First Name:TRUDIE
Middle Name:JANE
Last Name:ELLENBERGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SPRING DELL RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-5531
Mailing Address - Country:US
Mailing Address - Phone:717-397-6797
Mailing Address - Fax:
Practice Address - Street 1:1500 HIGHLANDS DR
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7694
Practice Address - Country:US
Practice Address - Phone:717-625-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003746L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100843265Medicaid
PA100843265Medicaid