1114000403 NPI number — THOMASENA L ELLISON MD FACOG

Table of content: THOMASENA L ELLISON MD FACOG (NPI 1114000403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114000403 NPI number — THOMASENA L ELLISON MD FACOG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
THOMASENA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD FACOG
Provider Gender Code:
F

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:
1114000403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 LIVINGSTON STREET
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-222-0393
Provider Business Mailing Address Fax Number:
718-222-3653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 LIVINGSTON STREET
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-222-0393
Provider Business Practice Location Address Fax Number:
718-222-3653
Provider Enumeration Date:
10/23/2006

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: 207V00000X , with the licence number:  1802491 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ET0249 . This is a "ATLANTIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: N323923 . This is a "WELL CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0202017 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112619613EL02 . This is a "CARE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C1694 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: P406658 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30310P . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: T4X . This is a "ETIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 255780401 . This is a "HEALTH PLUS" identifier . This identifiers is of the category "OTHER".




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