Provider Demographics
NPI:1548740848
Name:ELLIS HOSPITAL
Entity Type:Organization
Organization Name:ELLIS HOSPITAL
Other - Org Name:ELLIS PRIMARY CARE - GLENVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-243-4175
Mailing Address - Street 1:115 SARATOGA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4224
Mailing Address - Country:US
Mailing Address - Phone:518-243-3360
Mailing Address - Fax:
Practice Address - Street 1:115 SARATOGA RD STE 200
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4224
Practice Address - Country:US
Practice Address - Phone:518-243-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4601001H261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care