NPIMap

Individual provider Active NPI

Dustin Clay Ellis, M.D.

  • Family Medicine Physician
  • Sullivan, IN
National Provider Identifier
1962658989
Registry record updated Apr 27, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
11013685A Issued in IN
Practice address
2186 N Hospital Blvd Ste 2
Sullivan, IN 47882-7654
Phone
(812) 268-3318
NPI assigned
Aug 11, 2008
Last updated
Apr 27, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 27, 2021

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 11013685A IN Primary

Addresses

Primary practice location

2186 N Hospital Blvd Ste 2
Sullivan, IN 47882-7654

Mailing address

PO Box 230
2229 Mary Sherman Drive
Sullivan, IN 47882-0230
Phone (812) 268-3318

Other practice location 1

2229 Mary Sherman Dr
Sullivan, IN 47882-7633
Phone (812) 268-3318 ext. 206

Other identifiers 1

IdentifierTypeStateIssuer
200015680AMedicaidIN

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address dustin.ellis.1@8793.direct.athenahealth.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN
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
I20090406000246 IN Practitioner - Family PracticePractitioner - Obstetrics/Gynecology 3779630926 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: Obstetrics/Gynecology
Education
Indiana University School of Medicine, 2007
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

2186 N Hospital Blvd
2 Lakeside Family Medical
Sullivan, IN 47882-7654
Phone (812) 268-3318

2200 N Section St
Sullivan, IN 47882-7523
Phone (812) 268-4311

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Colonoscopy12
Upper gastrointestinal (GI) endoscopy for acid reflux1-10

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
11013685AINMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Sullivan County Community Hospital Family Medicine CurrentSince Oct 1, 2020 Accepting new patients
Sullivan Family Practice, LLC Family Medicine Current Accepting new patients
Mso Clinics, Inc. Past Accepting new patients

Locations

2186 N Hospital Blvd
Ste 2
Sullivan, IN 47882

2186 N Hospital Blvd
Ste 2
Sullivan, IN 47882
Phone (812) 268-3318

2200 N Section St
Sullivan, IN 47882
Phone (812) 268-6292

2200 N Section St
#A
Sullivan, IN 47882
Phone (812) 268-3318

2229 Mary Sherman Dr
Sullivan, IN 47882
Phone (812) 238-2100

340 N Section St
Med BLDG B
Sullivan, IN 47882
Phone (812) 268-6333

Interoperability endpoints

  • Direct secure messaging: dustin.ellis.1@8793.direct.athenahealth.com

Organizations & group practices 4

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 10

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": "1218412800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1619481600000",
    "number": "1962658989",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 230",
            "address_2": "2229 MARY SHERMAN DRIVE",
            "city": "SULLIVAN",
            "state": "IN",
            "postal_code": "478820230",
            "telephone_number": "812-268-3318",
            "fax_number": "812-268-4017"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2186 N HOSPITAL BLVD STE 2",
            "city": "SULLIVAN",
            "state": "IN",
            "postal_code": "478827654",
            "telephone_number": "812-268-3318"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2229 Mary Sherman Dr",
            "address_purpose": "LOCATION",
            "city": "Sullivan",
            "state": "IN",
            "postal_code": "478827633",
            "country_code": "US",
            "telephone_number": "812-268-3318 x206",
            "fax_number": "812-268-4017",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "DUSTIN",
        "middle_name": "CLAY",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-08-11",
        "last_updated": "2021-04-27",
        "certification_date": "2021-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "11013685A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200015680A",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "dustin.ellis.1@8793.direct.athenahealth.com",
            "affiliation": "N",
            "endpointDescription": "AthenaHealthcare EHR",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCDA",
            "address_1": "2186 N Hospital Blvd Ste 2",
            "city": "Sullivan",
            "state": "IN",
            "country_code": "US",
            "postal_code": "478827654",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Sullivan, IN

Sources for this page

Verify at the official NPI Registry.