Provider Demographics
NPI:1003019514
Name:ELLIS, BRENNAN (MD)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2342
Mailing Address - Country:US
Mailing Address - Phone:315-464-6202
Mailing Address - Fax:315-464-9501
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-6202
Practice Address - Fax:315-464-9501
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256992207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00890823OtherRAILROAD MEDICARE
NY03248175Medicaid
NYJ400025290Medicare PIN