Provider Demographics
NPI:1083859425
Name:THOMASENA L ELLISON MD PC
Entity Type:Organization
Organization Name:THOMASENA L ELLISON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMASENA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-222-0393
Mailing Address - Street 1:100 LIVINGSTON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5023
Mailing Address - Country:US
Mailing Address - Phone:718-222-0393
Mailing Address - Fax:
Practice Address - Street 1:100 LIVINGSTON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5023
Practice Address - Country:US
Practice Address - Phone:718-222-0393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1802491207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY79J911Medicare UPIN