Provider Demographics
NPI:1760484182
Name:ELLNER, SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:ELLNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:4320
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-5237
Mailing Address - Fax:860-714-8096
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:4320
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1770
Practice Address - Country:US
Practice Address - Phone:860-714-5237
Practice Address - Fax:860-714-8096
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043507208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001435074Medicaid
CTI31750Medicare UPIN
CTI31750Medicare UPIN