Individual
MARK L. ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3600 MINNESOTA DR STE 800, EDINA, MN 55435-7915
(952) 595-1301
(612) 294-4903
Mailing address
PO BOX 7695, COLUMBUS, MS 39705-0026
(662) 328-2476
(662) 327-4605
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
13170
MS
2085R0202X
Diagnostic Radiology Physician
13170
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00112542
—
MS
01
—
300124842
RAIL ROAD MEDICARE
MS
Enumeration date
06/23/2006
Last updated
12/05/2025
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