Provider Demographics
NPI:1760614317
Name:ELLIS HOSPITAL
Entity Type:Organization
Organization Name:ELLIS HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-243-4141
Mailing Address - Street 1:600 MCCLELLAN ST
Mailing Address - Street 2:2 WEST
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1009
Mailing Address - Country:US
Mailing Address - Phone:518-347-5400
Mailing Address - Fax:
Practice Address - Street 1:1101 NOTT ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308
Practice Address - Country:US
Practice Address - Phone:518-243-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-17
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4601001H1041C0700X, 207R00000X, 2080N0001X, 2084P0800X, 208600000X, 208M00000X, 208M00000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03177066Medicaid