Provider Demographics
NPI:1306006614
Name:NICHOLAS ELLYN, M.D., P.C.
Entity Type:Organization
Organization Name:NICHOLAS ELLYN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-578-0100
Mailing Address - Street 1:1707 OSAGE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2607
Mailing Address - Country:US
Mailing Address - Phone:703-578-0100
Mailing Address - Fax:703-824-8357
Practice Address - Street 1:1707 OSAGE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2607
Practice Address - Country:US
Practice Address - Phone:703-578-0100
Practice Address - Fax:703-824-8357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027634174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6380883Medicaid
1174626311OtherINDIVIDUAL NPI
1174626311OtherINDIVIDUAL NPI
VAB93983Medicare UPIN