Provider Demographics
NPI:1538672001
Name:JERI L ELLIS MD, MPH, PC
Entity Type:Organization
Organization Name:JERI L ELLIS MD, MPH, PC
Other - Org Name:ELLIS FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:CATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-470-1884
Mailing Address - Street 1:5909 NW EXPRESSWAY STE 360
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5149
Mailing Address - Country:US
Mailing Address - Phone:405-470-1884
Mailing Address - Fax:
Practice Address - Street 1:420 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6643
Practice Address - Country:US
Practice Address - Phone:400-581-6331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty