Provider Demographics
NPI:1679768675
Name:ELLIS, TERENCE B
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:B
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10537 S EWING AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-6220
Mailing Address - Country:US
Mailing Address - Phone:312-212-4570
Mailing Address - Fax:773-734-0407
Practice Address - Street 1:10537 S EWING AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6220
Practice Address - Country:US
Practice Address - Phone:312-212-4570
Practice Address - Fax:773-734-0407
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246X00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist Cardiovascular