1669418489 NPI number — MR. JACK W ELLERTSON PHYSICAL THERAPIST

Table of content: MR. JACK W ELLERTSON PHYSICAL THERAPIST (NPI 1669418489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669418489 NPI number — MR. JACK W ELLERTSON PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLERTSON
Provider First Name:
JACK
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
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:
1669418489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 WAYNE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMBERSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17201-2986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-264-6211
Provider Business Mailing Address Fax Number:
717-264-9816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1035 WAYNE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMBERSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17201-2986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-264-6211
Provider Business Practice Location Address Fax Number:
717-264-9816
Provider Enumeration Date:
06/21/2006

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: 225100000X , with the licence number:  PTO16235 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ELI1783757 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: ELI1783757 . This is a "FEDERAL BLUE SHIELD" identifier , issued by the state of ( PW ) . This identifiers is of the category "OTHER".
  • Identifier: 50056652 . This is a "CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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