Provider Demographics
NPI:1629443486
Name:SELENA ELLIS, M.D.
Entity Type:Organization
Organization Name:SELENA ELLIS, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-644-2282
Mailing Address - Street 1:3000 COLBY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2083
Mailing Address - Country:US
Mailing Address - Phone:510-644-2282
Mailing Address - Fax:510-644-1744
Practice Address - Street 1:3000 COLBY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2083
Practice Address - Country:US
Practice Address - Phone:510-644-2282
Practice Address - Fax:510-644-1744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADO533ZZMedicare PIN