1013046341 NPI number — DR. ELLIS B CHARLES M.D.

Table of content: DR. ELLIS B CHARLES M.D. (NPI 1013046341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013046341 NPI number — DR. ELLIS B CHARLES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLES
Provider First Name:
ELLIS
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1013046341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 LONGVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDOLPH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07869-3008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-895-5062
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07017-1050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-672-2555
Provider Business Practice Location Address Fax Number:
973-672-2529
Provider Enumeration Date:
03/04/2007

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: 2084P0800X , with the licence number:  132910 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 25MA05127300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0800X , with the licence number: 18284 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0866300 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".