Provider Demographics
NPI:1316002546
Name:PETER S. ELLIS, M.D., INC.
Entity Type:Organization
Organization Name:PETER S. ELLIS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-327-4647
Mailing Address - Street 1:5505 VIA SORENTO
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-9567
Mailing Address - Country:US
Mailing Address - Phone:661-373-7503
Mailing Address - Fax:
Practice Address - Street 1:420 34TH ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2237
Practice Address - Country:US
Practice Address - Phone:661-327-4647
Practice Address - Fax:661-326-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104110Medicaid
CAGR0104110Medicaid