Provider Demographics
NPI:1255652525
Name:ELLIS, JEREMY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6369
Mailing Address - Country:US
Mailing Address - Phone:610-969-4370
Mailing Address - Fax:
Practice Address - Street 1:1240 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6369
Practice Address - Country:US
Practice Address - Phone:610-969-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD448381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine