Matthew Liceralde Elloso, M.D.

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

4301096516 Issued in MI

Practice address

100 Michigan St NE
Suite A721
Grand Rapids, MI 49503-2560

Phone

(616) 391-3139

Fax

(616) 391-3044

NPI assigned

Jul 22, 2010

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: melloso49754@epic00.shdirect.org

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

• Michigan Medical Patient Care

  • Durable Medical Equipment & Medical Supplies
  • Holland, MI
  • NPI 1871741652
  NPD (past)

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

{
    "created_epoch": "1279756800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1624838400000",
    "number": "1447563150",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MICHIGAN ST NE",
            "address_2": "MC 845",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495032560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 MICHIGAN ST NE",
            "address_2": "SUITE A721",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495032560",
            "telephone_number": "616-391-3139",
            "fax_number": "616-391-3044"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLOSO",
        "first_name": "MATTHEW",
        "middle_name": "LICERALDE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-07-22",
        "last_updated": "2021-06-28",
        "certification_date": "2021-06-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "4301096516",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Averi Ellison
• Cherie Ellison, LMSW
• Elle K Ellison
• Sierra Ellison
• Steven Ellison
• Brandon D Ellsworth, MD
• Kathryn Ellsworth, M.A., CCC-SLP
• Laura Elluru
• Darryl A Elmouchi, MD
• Sarah Nicole Elmouchi, M.D.

• Internal Medicine Physician in Grand Rapids, MI
• Providers in Grand Rapids, MI by specialty
• Internal Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.