Provider Demographics
NPI:1144226630
Name:ELLISON, JAMES M (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 W 14TH ST
Mailing Address - Street 2:SWANK MEMORY CARE CENTER, GATEWAY BLDG 5TH FLOOR
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-1013
Mailing Address - Country:US
Mailing Address - Phone:302-320-2637
Mailing Address - Fax:844-634-0254
Practice Address - Street 1:501 W 14TH ST
Practice Address - Street 2:SWANK MEMORY CARE CENTER, GATEWAY BLDG, 5TH FLOOR
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1013
Practice Address - Country:US
Practice Address - Phone:302-320-2637
Practice Address - Fax:844-634-0254
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA449082084P0800X, 2084P0805X
DEC-00114432084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0164127Medicaid
MA0164127Medicaid
MAB11718Medicare ID - Type Unspecified