Provider Demographics
NPI:1174581623
Name:ELLIS, RICHARD ALAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-4692
Mailing Address - Fax:
Practice Address - Street 1:7705 POPLAR AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3930
Practice Address - Country:US
Practice Address - Phone:901-516-6300
Practice Address - Fax:901-516-6350
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16474208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014601Medicaid
TN6042000OtherBCBS
TN103I023076Medicare PIN
TNQ014601Medicaid