Provider Demographics
NPI:1265511794
Name:ELLIS, ANDY D (HS2)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:M
Credentials:HS2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USCG HQ, COMDT
Mailing Address - Street 2:(CG-1122)
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USCG HQ, COMDT
Practice Address - Street 2:(CG-1122)
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201
Practice Address - Country:US
Practice Address - Phone:757-483-8596
Practice Address - Fax:757-483-8596
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider