Provider Demographics
NPI:1316357411
Name:ELLIS, ROGER STEPHEN (MD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:STEPHEN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 EDGEHILL WAY
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127
Mailing Address - Country:US
Mailing Address - Phone:419-681-4404
Mailing Address - Fax:415-375-7500
Practice Address - Street 1:301 EDGEHILL WAY
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127
Practice Address - Country:US
Practice Address - Phone:419-681-4404
Practice Address - Fax:415-375-7500
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40749207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G407490Medicare UPIN