Provider Demographics
NPI:1497873350
Name:ELLIS, GEORGE C (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
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 1:1185 PARK AVENUE
Mailing Address - Street 2:# 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1310
Mailing Address - Country:US
Mailing Address - Phone:212-722-6613
Mailing Address - Fax:212-722-6835
Practice Address - Street 1:1185 PARK AVENUE
Practice Address - Street 2:# 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1310
Practice Address - Country:US
Practice Address - Phone:212-722-6613
Practice Address - Fax:212-722-6835
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124505207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
331281Medicare ID - Type Unspecified
D39082Medicare UPIN