Provider Demographics
NPI:1629338736
Name:CHRISTIAN ELLIS MD PLC
Entity Type:Organization
Organization Name:CHRISTIAN ELLIS MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-404-6641
Mailing Address - Street 1:300 DUNES BLVD APT 704
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-6438
Mailing Address - Country:US
Mailing Address - Phone:239-404-6641
Mailing Address - Fax:
Practice Address - Street 1:11181 HEALTH PARK BLVD STE 1170
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-5734
Practice Address - Country:US
Practice Address - Phone:239-596-8814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101183261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center