Provider Demographics
NPI:1073708251
Name:GEORGE G ELLIS JR MD INC
Entity Type:Organization
Organization Name:GEORGE G ELLIS JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-965-0832
Mailing Address - Street 1:910 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4240
Mailing Address - Country:US
Mailing Address - Phone:330-965-0832
Mailing Address - Fax:330-965-0155
Practice Address - Street 1:910 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4240
Practice Address - Country:US
Practice Address - Phone:330-965-0832
Practice Address - Fax:330-965-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060641E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0894500Medicaid
OH2316989Medicaid
OH2316989Medicaid
OHF13547Medicare UPIN