Individual ProviderEllisa KrummFamily MedicineAllopathic & Osteopathic PhysiciansPractice Address1500 S Main St, Fort Worth, TX 76104-4917(817) 702-1204PECOS EnrollmentBased on the most recent information from CMS, provider Ellisa Krumm is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1124105457Provider TypeIndividualFull NameKrumm, EllisaCredentialMDGenderFemaleSole ProprietorNoEnumeration Date11/1/2006Last Updated6/6/2017Contact InformationPractice LocationPractice Address1500 S Main St, Fort Worth, TX 76104-4917Phone(817) 702-1204FaxUnlisted FaxMailing LocationMailing Address1500 S Main St, Fort Worth, TX 76104-4917Phone(817) 702-1204FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode207Q00000XPrimaryDescriptionFamily MedicineAllopathic & Osteopathic PhysiciansLicenseQ2699TexasCode207Q00000XDescriptionFamily MedicineAllopathic & Osteopathic PhysiciansLicense45018TennesseeCode207Q00000XDescriptionFamily MedicineAllopathic & Osteopathic PhysiciansLicenseLL28867South CarolinaProvider IdentifiersIDDescriptionIssuerID1513688DescriptionMedicaidIssuerUnlistedTennessee