Provider Demographics
NPI:1003029224
Name:SCHWARTZ, ELLISSA A (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ELLISSA
Middle Name:A
Last Name:SCHWARTZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ELLISSA
Other - Middle Name:A
Other - Last Name:METTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:6830 VILLAGREEN VIEW
Mailing Address - Street 2:OSF MEDICAL GROUP-SPRINGCREEK
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5639
Mailing Address - Country:US
Mailing Address - Phone:815-282-1339
Mailing Address - Fax:815-282-1298
Practice Address - Street 1:6830 VILLAGREEN VW
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5639
Practice Address - Country:US
Practice Address - Phone:815-282-1339
Practice Address - Fax:815-282-1298
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002771363A00000X
PAMA #052890363A00000X
WI2370-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553180OtherMEDICARE GROUP PTAN
IL834340OtherMEDICARE GROUP PTAN
IL846930OtherMEDICARE GROUP PTAN
IL846930OtherMEDICARE GROUP PTAN
IL846930002Medicare PIN
IL834340018Medicare PIN