Provider Demographics
NPI:1679508352
Name:ELLIS, RODNEY JAY (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:JAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 858 MC A410
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:717-531-0882
Practice Address - Street 1:500 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-0858
Practice Address - Country:US
Practice Address - Phone:800-243-1455
Practice Address - Fax:717-531-0882
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4677782085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0312692Medicaid
OHEL0811888Medicare ID - Type Unspecified
OHEL4293491Medicare PIN
OH0312692Medicaid
OHP00888402Medicare PIN