Provider Demographics
NPI:1568423366
Name:ELLIS, JEROME KEEFER (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:KEEFER
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 1:24 CREE DR
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-2639
Mailing Address - Country:US
Mailing Address - Phone:570-893-5000
Mailing Address - Fax:
Practice Address - Street 1:24 CREE DR
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2639
Practice Address - Country:US
Practice Address - Phone:570-893-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069228L207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA028223Medicare ID - Type Unspecified
G96563Medicare UPIN