1730218520 NPI number — J. SCOTT ELLIS, DO, PA

Table of content: STACEY RACHELLE HVINDEN PHARM D. (NPI 1598015612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730218520 NPI number — J. SCOTT ELLIS, DO, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. SCOTT ELLIS, DO, 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:
Provider Other Organization Name Type Code:
6
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:
1730218520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3023 PERRYTON PKWY
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
PAMPA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79065-2821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-665-9900
Provider Business Mailing Address Fax Number:
806-665-9905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3023 PERRYTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
PAMPA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79065-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-665-9900
Provider Business Practice Location Address Fax Number:
806-665-9905
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
JIMMY
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
806-665-9900

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  L6229 , 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)

  • Identifier: 0042KD . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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