Provider Demographics
NPI:1003567074
Name:ELLINGTON, MARCUS AYINDE
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:AYINDE
Last Name:ELLINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3460
Mailing Address - Country:US
Mailing Address - Phone:317-270-8973
Mailing Address - Fax:
Practice Address - Street 1:701 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1578
Practice Address - Country:US
Practice Address - Phone:317-270-8973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer