Individual
MR. ROBERT ELLSWORTH ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
9115 LEESGATE RD, SUITE C, LOUISVILLE, KY 40222-5003
(502) 719-0782
(502) 719-0787
Mailing address
9115 LEESGATE RD, SUITE C, LOUISVILLE, KY 40222-5003
(502) 719-0782
(502) 719-0787
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
19194
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000047003
ANTHEM
KY
01
—
1058692
PASSPORT
KY
01
—
110000678
MEDICARE RR
KY
01
—
2433985000
PASSPORT ADVANTAGE
KY
05
—
64191943
—
KY
Enumeration date
05/05/2006
Last updated
08/13/2009
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