Provider Demographics
NPI:1902386485
Name:ELLIS HOSPITAL
Entity Type:Organization
Organization Name:ELLIS HOSPITAL
Other - Org Name:ELLIS PRIMARY CARE & FAMILY MEDICINE RESIDENCY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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:518-243-4175
Mailing Address - Street 1:624 MCCLELLAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1020
Mailing Address - Country:US
Mailing Address - Phone:518-382-2260
Mailing Address - Fax:
Practice Address - Street 1:624 MCCLELLAN ST STE 101
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1020
Practice Address - Country:US
Practice Address - Phone:518-382-2260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLIS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4601001H261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care