Provider Demographics
NPI:1578574422
Name:ELLIS MEZ, MD, PA
Entity Type:Organization
Organization Name:ELLIS MEZ, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:410-795-7737
Mailing Address - Street 1:1645 LIBERTY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6521
Mailing Address - Country:US
Mailing Address - Phone:410-795-7737
Mailing Address - Fax:410-795-2828
Practice Address - Street 1:1645 LIBERTY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6521
Practice Address - Country:US
Practice Address - Phone:410-795-7737
Practice Address - Fax:410-795-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD277541700Medicaid
S136-1-11-0Medicare ID - Type Unspecified