NPIMap

Individual provider Active NPI

Mark Brian Ellis, D.O.

  • Family Medicine Physician
  • Enterprise, AL
National Provider Identifier
1083632244
Registry record updated Apr 4, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
DO463 Issued in AL
Practice address
1018 Rucker Blvd
Ste a
Enterprise, AL 36330-3675
Phone
(334) 347-4343
Fax
(334) 393-9611
NPI assigned
Jul 17, 2006
Last updated
Apr 4, 2018By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X DO463 AL Primary

Addresses

Primary practice location

1018 Rucker Blvd
Ste a
Enterprise, AL 36330-3675

Mailing address

1018 Rucker Blvd
Ste a
Enterprise, AL 36330-3675
Phone (334) 347-4343

Other identifiers 1

IdentifierTypeStateIssuer
009971495MedicaidAL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040518000754 AL Practitioner - Family PracticePractitioner - Internal Medicine 3971593138 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: Internal Medicine
Education
Kansas City University of Med & Biosciences, College of Osteo Med, 1994
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Dale Medical CenterGroup PAC ID 3476466327, 29 clinicians

Practice addresses (Care Compare)

1519 Andrews Ave
Ozark, AL 36360-3719
Phone (334) 774-7610

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
DO463ALMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Southland Medical Solutions of Ozark, PL CurrentSince Mar 18, 2021 Accepting new patients
Dale Medical Center CurrentSince May 1, 2019 Accepting new patients
Dale Medical Center Family Medicine CurrentSince May 1, 2019 Accepting new patients
Dale Medical Center Family Medicine Current Accepting new patients
Primeteam, Inc. Past Accepting new patients
Dale Medical Center Past Accepting new patients
Dale Medical Center Family Medicine Past Accepting new patients
Primecare of Dothan, PC Past Accepting new patients

Locations

126 Hospital Ave
Ozark, AL 36360
Phone (334) 445-4803

1519 Andrews Ave
Ozark, AL 36360
Phone (334) 774-7610

218 Hospital Ave
Ste C
Ozark, AL 36360
Phone (334) 774-1049

359 James St
Ozark, AL 36360
Phone (334) 774-6712

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153094400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1522800000000",
    "number": "1083632244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1018 RUCKER BLVD",
            "address_2": "STE A",
            "city": "ENTERPRISE",
            "state": "AL",
            "postal_code": "363303675",
            "telephone_number": "334-347-4343",
            "fax_number": "334-393-9611"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1018 RUCKER BLVD",
            "address_2": "STE A",
            "city": "ENTERPRISE",
            "state": "AL",
            "postal_code": "363303675",
            "telephone_number": "334-347-4343",
            "fax_number": "334-393-9611"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "MARK",
        "middle_name": "BRIAN",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-17",
        "last_updated": "2018-04-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AL",
            "license": "DO463",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "009971495",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Enterprise, AL

Sources for this page

Verify at the official NPI Registry.