Darren R. Ellenbolt, M.D.
Individual provider Active NPI Family Medicine Physician · Mukwonago, WI
NPI 1700855012 · NPPES record last updated Nov 2, 2011
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128b(4) exclusion effective Sep 19, 2024.
Key facts
- NPI
- 1700855012
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 47860 (WI)
- Practice address
- 240 Maple Ave.
Prohealth Care Medical Associates, Inc.
Mukwonago, WI 53149-8475 - Phone
- (262) 928-1900
- Fax
- (262) 363-1949
- NPI assigned
- Mar 17, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- HHS exclusion list flag
- The National Provider Directory flags this NPI as appearing on an HHS exclusion list.
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 47860 | WI | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Prohealth Medical Group Inc | Family Medicine | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 47860 | WI | Yes |
Addresses
Primary practice location
240 Maple Ave.
Prohealth Care Medical Associates, Inc.
Mukwonago, WI 53149-8475
Mailing address
N17 W24100 Riverwood Dr.
Prohealth Care Medical Associates, Inc.
Waukesha, WI 53188-1177
Phone (262) 928-4100
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 34847400 | Medicaid | WI |
Other providers in Mukwonago, WI
- Alyssa Doyle
- Julie A. Doyle
- Melissa Eichler
- Einar C. Svang II DDS SC
- Elite Performance Chiropractic, LLC
- Jessica Lynn Elliott
- Joshua E Erdtmann
- Patricia Ann Evans
- Family Vision & Contact Lens CTRS SC
- Steven C. Fehr
All providers in Mukwonago, WI · Family Medicine Physician in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 2, 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.
- OIG LEIE (HHS Office of Inspector General).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.