1427337500 NPI number — TONYA M ELLIS PT, DPT

Table of content: (NPI 1124016514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427337500 NPI number — TONYA M ELLIS PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
TONYA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1427337500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7567 CENTRAL PARKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45040-6852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-701-6100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2859 BOUDINOT AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45238-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-701-6520
Provider Business Practice Location Address Fax Number:
513-701-6521
Provider Enumeration Date:
08/08/2011

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: 225100000X , with the licence number:  PT.012729 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0214940 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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