Provider Demographics
NPI:1598739187
Name:ELLIS, MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W MARKET ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4602
Mailing Address - Country:US
Mailing Address - Phone:419-224-8007
Mailing Address - Fax:419-516-4881
Practice Address - Street 1:750 W MARKET ST STE 200
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-516-6032
Practice Address - Fax:419-516-4881
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3567111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00374677OtherPALMETTO GBA MEDICARE RR
OH2600662Medicaid
OH000000383249OtherANTHEM BC/BS
OHU98168Medicare UPIN
OH4169901Medicare ID - Type Unspecified