1962465971 NPI number — DR. JOHN E ELLIS O.D.

Table of content: DR. JOHN E ELLIS O.D. (NPI 1962465971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962465971 NPI number — DR. JOHN E ELLIS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
JOHN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.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:
1962465971
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
619 E CRAWFORD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONNELLSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15425-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-628-1370
Provider Business Mailing Address Fax Number:
724-628-7314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
619 E CRAWFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONNELLSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15425-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-628-1370
Provider Business Practice Location Address Fax Number:
724-628-7314
Provider Enumeration Date:
04/10/2006

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: 152W00000X , with the licence number:  OEG001091 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0009205 . This is a "DORAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 397414 . This is a "ADVANTRA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 397414 . This is a "HEALTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00230647 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1451095 . This is a "UMWA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0014138740003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 137989 . This is a "EYEMED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: EL715656 . This is a "PA BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 123681 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 03770 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 118173 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 207741 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".