Basic Information
| Provider Information | |||||||||
| NPI: | 1972867521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRANCIS | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 S BRYN MAWR AVE | ||||||||
| Address2: | SUITE H321 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843374097 | ||||||||
| FaxNumber: | 4843374082 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 S BRYN MAWR AVE | ||||||||
| Address2: | SUITE H321 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843374097 | ||||||||
| FaxNumber: | 4843374082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2012 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | OS017652 | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | OS017652 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.