1669427118 NPI number — JOHNNY R. ELLISON D.O.

Table of content: KAREN A CORWELL RN (NPI 1881904548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669427118 NPI number — JOHNNY R. ELLISON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
JOHNNY
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1669427118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-446-5000
Provider Business Mailing Address Fax Number:
740-446-5625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1051 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLIPOLIS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45631-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-446-5244
Provider Business Practice Location Address Fax Number:
740-446-5625
Provider Enumeration Date:
05/23/2006

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: 207Q00000X , with the licence number:  34-00-3700 , 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: 001714065 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0555340 . This is a "MOLINA MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000181981 . This is a "UNISON MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 310917085105 . This is a "CARESOURCE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0051040000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000007522 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0555340 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080056559 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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