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Individual

ELLEN MIDDENDORF

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
MD

Contact information

Practice address
4600 MEMORIAL DR, STE. 160, BELLEVILLE, IL 62226-5368
(618) 235-0460
(618) 235-1464
Mailing address
4600 MEMORIAL DR, STE. 160, BELLEVILLE, IL 62226-5368
(618) 235-0460
(618) 235-1464

Taxonomy

Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036-108143
IL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
036108143
IL
05
1245234988
IL
Enumeration date
06/10/2005
Last updated
05/24/2012
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