1427311455 NPI number — DR. JOHN ELLIE JR. D.P.M.

Table of content: DR. JOHN ELLIE JR. D.P.M. (NPI 1427311455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427311455 NPI number — DR. JOHN ELLIE JR. D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIE
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.P.M.
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:
1427311455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 PORTLAND AVE
Provider Second Line Business Mailing Address:
PODIATRY/MED OFFICE
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-642-6100
Provider Business Mailing Address Fax Number:
585-642-6111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 PORTLAND AVE
Provider Second Line Business Practice Location Address:
PODIATRY SUITE
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621-3065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-642-6100
Provider Business Practice Location Address Fax Number:
585-642-6111
Provider Enumeration Date:
06/25/2012

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: 213ES0103X , with the licence number:  006649 , 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: 05448155 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04203352 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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