Provider Demographics
NPI:1376509323
Name:ELLIS, COREY JAMES (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:JAMES
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 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-2091
Practice Address - Fax:937-208-6141
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084741207QS0010X
OH35.0847412080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2511446Medicaid
OH2511446Medicaid
4144185Medicare PIN