Provider Demographics
NPI:1538471305
Name:ELLIS, PREETIVI (MD FACP)
Entity type:Individual
Prefix:DR
First Name:PREETIVI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3377 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8803
Mailing Address - Country:US
Mailing Address - Phone:541-222-6389
Mailing Address - Fax:541-222-6385
Practice Address - Street 1:PEACEHEALTH HOSPITAL MEDICINE
Practice Address - Street 2:3377 RIVERBEND DRIVE
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8803
Practice Address - Country:US
Practice Address - Phone:541-222-6389
Practice Address - Fax:541-222-6385
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122222207R00000X, 207R00000X, 207RG0300X
ORMD166207208M00000X
TXR1515208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208M00000XMedicaid