Provider Demographics
NPI:1275616880
Name:ELLIS, THEODORE R (PT)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:R
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:150 STRAFFORD AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3114
Mailing Address - Country:US
Mailing Address - Phone:610-971-6969
Mailing Address - Fax:610-971-9444
Practice Address - Street 1:150 STRAFFORD AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3114
Practice Address - Country:US
Practice Address - Phone:610-971-6969
Practice Address - Fax:610-971-9444
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPT008710E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002166RCRMedicare PIN