1740349661 NPI number — JON M. ELLIS, MD PA

Table of content: (NPI 1740349661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740349661 NPI number — JON M. ELLIS, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JON M. ELLIS, MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHWEST SPORTS MEDICINE AND ORTHOPAEDICS
Provider Other Organization Name Type Code:
3
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:
1740349661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7030 NEW SANGER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76712-3991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-774-1140
Provider Business Mailing Address Fax Number:
254-741-1428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7030 NEW SANGER RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76712-3991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-774-1140
Provider Business Practice Location Address Fax Number:
254-741-1428
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROHRER
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
254-741-1400

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  J9580 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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