NPIMap

Individual provider Active NPI

Marie Ellen Ellis, DO

  • Internal Medicine Physician
  • Burbank, IL
National Provider Identifier
1639631583
Registry record updated Oct 5, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
036-158239 Issued in IL
Practice address
6345 W 79TH St
Burbank, IL 60459-1133
Phone
(312) 609-0300
NPI assigned
Apr 1, 2019
Last updated
Oct 5, 2022By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 5, 2022

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 036-158239 IL Primary

Addresses

Primary practice location

6345 W 79TH St
Burbank, IL 60459-1133

Mailing address

29373 Network PL
Chicago, IL 60673-1005
Phone (847) 390-5900

Electronic endpoints 2

TypeEndpointUseAffiliation
Direct Messaging Address mellis229423@direct.myadvocateaurora.org Direct
FHIR URL https://EpicFHIR.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
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
I20220913001421 IL Practitioner - Internal Medicine 2365827243 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Lake Erie College of Osteopathic Medicine, Erie, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

6345 W 79TH St
Burbank, IL 60459-1133
Phone (708) 499-1545

Hospital & facility affiliations

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
036-158239ILMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Advocate Health and Hospitals Corporation CurrentSince Jul 29, 2022 Accepting new patients
Advocate Health and Hospitals Corporation Current Accepting new patients
Advocate Health & Hospitals Corporation CurrentSince Jul 29, 2022 Accepting new patients

Locations

214 McHenry Rd
Buffalo Grove, IL 60089
Phone (847) 459-1160

6345 W 79th St
Burbank, IL 60459
Phone (844) 725-5238

29373 Network Pl
Chicago, IL 60673

1775 Ballard Rd
Park Ridge, IL 60068
Phone (847) 318-6020

Interoperability endpoints

  • Direct secure messaging: mellis229423@direct.myadvocateaurora.org

Organizations & group practices 3

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 6

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": "1554076800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664928000000",
    "number": "1639631583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "29373 NETWORK PL",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606731005",
            "telephone_number": "847-390-5900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6345 W 79TH ST",
            "city": "BURBANK",
            "state": "IL",
            "postal_code": "604591133",
            "telephone_number": "312-609-0300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "MARIE",
        "middle_name": "ELLEN",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-04-01",
        "last_updated": "2022-10-05",
        "certification_date": "2022-10-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IL",
            "license": "036-158239",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "mellis229423@direct.myadvocateaurora.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "6345 W 79th St",
            "city": "Burbank",
            "state": "IL",
            "country_code": "US",
            "postal_code": "604591133",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://EpicFHIR.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/",
            "affiliation": "N",
            "address_1": "6345 W 79th St",
            "city": "Burbank",
            "state": "IL",
            "country_code": "US",
            "postal_code": "604591133",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Burbank, IL

Sources for this page

Verify at the official NPI Registry.