Active NPI
Jared S Ellis, MD
- Family Medicine Physician
- Tuscaloosa, AL
National Provider Identifier
1790785756
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 17418
- Practice address
- 2201 Jack Warner Pkwy
Tuscaloosa, AL 35401-1090 - Phone
- (205) 523-5618
- NPI assigned
- Jul 29, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 17418 | AL | Primary |
Addresses
Primary practice location
2201 Jack Warner Pkwy
Tuscaloosa, AL 35401-1090
Mailing address
2201 Jack Warner Pkwy
Tuscaloosa, AL 35401-1090
Phone (205) 523-5618
Other identifiers 6
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1750393682 | Medicaid | AL | |
| 541392605 | Medicaid | AL | |
| 1750393682 | Other | AL | GROUP NPI # |
| 529700760 | Medicaid | AL | |
| 541003926 | Medicaid | AL | |
| 051037554 | Medicaid | AL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in AL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240610001711 | AL | Order and Referring Only - Family Practice | 6608784830 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 17418 | AL | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1122595200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1661990400000",
"number": "1790785756",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2201 JACK WARNER PKWY",
"city": "TUSCALOOSA",
"state": "AL",
"postal_code": "354011090",
"telephone_number": "205-523-5618"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2201 JACK WARNER PKWY",
"city": "TUSCALOOSA",
"state": "AL",
"postal_code": "354011090",
"telephone_number": "205-523-5618"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLIS",
"first_name": "JARED",
"middle_name": "S",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-07-29",
"last_updated": "2022-09-01",
"certification_date": "2022-09-01",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "AL",
"license": "17418",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1750393682",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "541392605",
"state": "AL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "GROUP NPI #",
"identifier": "1750393682",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "529700760",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "541003926",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "051037554",
"state": "AL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Tuscaloosa, AL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.