Provider Demographics
NPI:1306822408
Name:MACE, ELLEN NMN (DO)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:NMN
Last Name:MACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELLEN
Other - Middle Name:MACE
Other - Last Name:LEIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:FCI SCHUYLKILL - HEALTH SERVICES
Mailing Address - City:MINERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17954-0700
Mailing Address - Country:US
Mailing Address - Phone:570-544-7100
Mailing Address - Fax:570-544-7224
Practice Address - Street 1:INTERSTATE 81 & 901 W
Practice Address - Street 2:FCI SCHUYLKILL - HEALTH SERVICES
Practice Address - City:MINERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17954-0700
Practice Address - Country:US
Practice Address - Phone:570-544-7100
Practice Address - Fax:570-544-7224
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1000582000Medicaid
WV1000582000Medicaid
WV1000582000Medicaid
WVH54913Medicare UPIN