Provider Demographics
NPI:1770842874
Name:ELLIS, COLIN (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 PENN SQUARE BLVD
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:267-425-9232
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3500 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:215-590-1771
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4584362084N0400X
PAMT2011832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology