Individual
LESLIE R ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4123 DUTCHMANS LN STE 301, LOUISVILLE, KY 40207-4721
(502) 896-2500
(502) 896-2527
Mailing address
PO BOX 776879, CHICAGO, IL 60677-6879
(502) 272-5395
(502) 272-5339
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
35733
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000744501
ANTHEM- KCNS
KY
05
—
200439570
—
IN
01
—
50035433
PASSPORT- KCNS
KY
05
—
64067267
—
KY
Enumeration date
03/14/2006
Last updated
09/14/2021
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