Basic Information
| Provider Information | |||||||||
| NPI: | 1154307601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9346194366 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 N PICKAWAY ST | ||||||||
| Address2: | |||||||||
| City: | CIRCLEVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431131447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404742126 | ||||||||
| FaxNumber: | 7404771022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 08/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34-00-6876 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2372838 | 05 | OH | MEDICAID | 000000372264 | 01 | OH | BLUE CROSS BLUE SHIELD | OTHER |