Provider Demographics
NPI:1659617090
Name:THOMAS P ELLIS DC PA
Entity Type:Organization
Organization Name:THOMAS P ELLIS DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-341-1234
Mailing Address - Street 1:214 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1251
Mailing Address - Country:US
Mailing Address - Phone:727-341-1234
Mailing Address - Fax:727-345-0843
Practice Address - Street 1:214 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1251
Practice Address - Country:US
Practice Address - Phone:727-341-1234
Practice Address - Fax:727-345-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH00004294111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051111100Medicaid
FL051111100Medicaid