Provider Demographics
NPI:1851848360
Name:JONATHAN ELLEN MD PC
Entity Type:Organization
Organization Name:JONATHAN ELLEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-484-2052
Mailing Address - Street 1:PO BOX 1000 DEPT 0420
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0420
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:901-821-0341
Practice Address - Street 1:4441 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8267
Practice Address - Country:US
Practice Address - Phone:901-484-2052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty