1740349661 NPI number — JON M. ELLIS, MD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740349661 NPI number — JON M. ELLIS, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JON M. ELLIS, MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHWEST SPORTS MEDICINE AND ORTHOPAEDICS
Provider Other Organization Name Type Code:
3
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:
1740349661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7030 NEW SANGER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76712-3991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-774-1140
Provider Business Mailing Address Fax Number:
254-741-1428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7030 NEW SANGER RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76712-3991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-774-1140
Provider Business Practice Location Address Fax Number:
254-741-1428
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROHRER
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
254-741-1400

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  J9580 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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