Provider Demographics
NPI:1477635522
Name:EBERT, ELLEN C (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:EBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CLYDE RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5041
Mailing Address - Country:US
Mailing Address - Phone:732-873-1600
Mailing Address - Fax:732-873-1606
Practice Address - Street 1:17 CLYDE RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5041
Practice Address - Country:US
Practice Address - Phone:732-873-1600
Practice Address - Fax:732-873-1606
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA04369900174400000X
NJ25MA04369900207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0174602Medicaid
NJ403897Medicare PIN
NJ0174602Medicaid