1366583163 NPI number — JASON MAX ELLIS D.C.

Table of content: JASON MAX ELLIS D.C. (NPI 1366583163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366583163 NPI number — JASON MAX ELLIS D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
JASON
Provider Middle Name:
MAX
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1366583163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 WELCH RD
Provider Second Line Business Mailing Address:
STE 111
Provider Business Mailing Address City Name:
COMMERCE TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48390-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-779-9290
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4010 PAGE AVE
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
MICHIGAN CENTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49254-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-489-4044
Provider Business Practice Location Address Fax Number:
248-489-4055
Provider Enumeration Date:
02/12/2007

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: 111NN1001X , with the licence number:  2301008416 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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