Basic Information
| Provider Information | |||||||||
| NPI: | 1619504958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | NIGEL HUGH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 DUNCAN DR APT 8 | ||||||||
| Address2: | |||||||||
| City: | FAIRBORN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453242079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609830021 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4614 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
| FaxNumber: | 3367165168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2020 | ||||||||
| LastUpdateDate: | 03/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.