Individual
DR. MARK R. ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2900 S NATIONAL AVE, SPRINGFIELD, MO 65804-3634
(417) 269-1499
(417) 269-1459
Mailing address
PO BOX 4046, SPRINGFIELD, MO 65808-4046
(417) 269-5712
(417) 269-7567
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
103675
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
121334
BLUE CROSS
—
05
—
208184820
—
MO
Enumeration date
08/30/2006
Last updated
03/26/2018
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