1104950989 NPI number — BLAIR AND ELLIS P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104950989 NPI number — BLAIR AND ELLIS P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLAIR AND ELLIS P.A.
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:
1104950989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 N MESA ST STE B1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79902-1535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-533-1811
Provider Business Mailing Address Fax Number:
915-533-3641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 N MESA ST STE B1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79902-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-533-1811
Provider Business Practice Location Address Fax Number:
915-533-3641
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
915-533-1811

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 160388801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180559001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35FC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 96256028 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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