1932577921 NPI number — ANDREW ELLARD PT

Table of content: ANDREW ELLARD PT (NPI 1932577921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932577921 NPI number — ANDREW ELLARD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLARD
Provider First Name:
ANDREW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1932577921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 FIELDSTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDENDALE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35071-2590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-508-2277
Provider Business Practice Location Address Fax Number:
225-246-8730
Provider Enumeration Date:
09/08/2015

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: 225100000X , with the licence number:  09031R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OTT.200871 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PTH8128 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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