Individual
DR. RUSTY TODD ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1025 NEW MOODY LN, LA GRANGE, KY 40031-9154
(502) 222-8535
(502) 222-3932
Mailing address
PO BOX 950248, LOUISVILLE, KY 40295-0248
(502) 253-1035
(502) 253-1037
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
43074
KY
208M00000X
Hospitalist Physician
Primary
43074
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000633242
ANTHEM
KY
01
—
50026571
PASSPORT
KY
05
—
7100094070
—
KY
Enumeration date
02/28/2007
Last updated
12/04/2020
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