Carolyn Ann Ellsworth, M.D.
Individual provider Active NPI Pediatric Adolescent Medicine Physician · West Plains, MO
NPI 1679570618 · NPPES record last updated Nov 1, 2011
Key facts
- NPI
- 1679570618
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Adolescent Medicine Physician 2080A0000X
- License
- 102421 (MO)
- Practice address
- 312 N Kentucky St
West Plains, MO 65775-2073 - Phone
- (417) 257-7076
- Fax
- (417) 257-1417
- NPI assigned
- Jul 6, 2005
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180131000915 | MO | Practitioner - Pediatric Medicine | 4183984743 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 102421 | MO | MD | Pediatric Adolescent Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Ozarks Medical Center | Current |
Accepting new patients | |
| Ozarks Medical Center | Current |
Accepting new patients | |
| Ozarks Medical Center | Past | Accepting new patients |
Locations
312 N Kentucky Ave
West Plains, MO 65775
Phone (417) 257-7076
1100 N Kentucky Ave
West Plains, MO 65775
Phone (417) 257-5959
Interoperability endpoints
- carolynellsworth@omcmo.allscriptsdirect.net
- dr.ellsworth@mhccaremail.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Adolescent Medicine Physician | 2080A0000X | 102421 | MO | Yes |
Addresses
Primary practice location
312 N Kentucky St
West Plains, MO 65775-2073
Mailing address
312 N Kentucky St
West Plains, MO 65775-2073
Phone (417) 257-7076
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 123942001 | Medicaid | AK | |
| 203592001 | Medicaid | MO |
Other providers in West Plains, MO
- Sara Eidson
- Audrey Clae Eldringhoff
- Elite Chiropractic of the Ozarks, LLC
- Emily Elliott
- Trease P Ellison
- Empower Therapy Services, LLC
- Empowerme Rehabilitation Missouri LLC
- Maria Eskandar
- Michael Eskew
- Ada R Evans
All providers in West Plains, MO · Pediatric Adolescent Medicine Physician in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 1, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.