Provider Demographics
NPI:1861450504
Name:ELLINGWORTH, BRIAN JON (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JON
Last Name:ELLINGWORTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6076
Mailing Address - Country:US
Mailing Address - Phone:507-386-6600
Mailing Address - Fax:507-625-5971
Practice Address - Street 1:1431 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-386-6700
Practice Address - Fax:507-388-8372
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103183C572OtherUCARE MN
MN6404967OtherMEDICA, WATERVILLE
MN983181027668OtherPREFERRED ONE
MN11F45ELOtherBCBS OF MN
MN6404857OtherMEDICA, MANKATO
MNH035OtherTRICARE
MNHP43586OtherHEALTH PARTNERS