1932254083 NPI number — CRAIG M ELLISON MD

Table of content: CRAIG M ELLISON MD (NPI 1932254083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932254083 NPI number — CRAIG M ELLISON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
CRAIG
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1932254083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17334
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-443-6717
Provider Business Mailing Address Fax Number:
703-443-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 KENMORE AVE
Provider Second Line Business Practice Location Address:
SUITE #305
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-1313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-751-5763
Provider Business Practice Location Address Fax Number:
703-370-8704
Provider Enumeration Date:
01/25/2007

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: 207RG0100X , with the licence number:  0101234566 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00777103 . This is a "RR MEDICARE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1932254083 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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