1730283813 NPI number — ANDREW P ELLIS PHD

Table of content: ANDREW P ELLIS PHD (NPI 1730283813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730283813 NPI number — ANDREW P ELLIS PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
ANDREW
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730283813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7204 SW DURHAM RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-941-9869
Provider Business Mailing Address Fax Number:
503-352-5555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1815 SW MARLOW
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-292-0765
Provider Business Practice Location Address Fax Number:
503-292-5208
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  1396 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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