Provider Demographics
NPI:1558441790
Name:ELLIS, JAY M (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6941
Mailing Address - Country:US
Mailing Address - Phone:413-499-7128
Mailing Address - Fax:413-447-1926
Practice Address - Street 1:100 WENDELL AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6941
Practice Address - Country:US
Practice Address - Phone:413-499-7128
Practice Address - Fax:413-447-1926
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA408122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2051842Medicaid
MAI22245Medicare ID - Type Unspecified
MAB99530Medicare UPIN