Provider Demographics
NPI:1912028804
Name:ELLMAN REHAB ASSOCIATES PA
Entity Type:Organization
Organization Name:ELLMAN REHAB ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:ELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-682-3909
Mailing Address - Street 1:PO BOX 850304
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-0304
Mailing Address - Country:US
Mailing Address - Phone:972-682-3909
Mailing Address - Fax:972-682-9289
Practice Address - Street 1:2692 N GALLOWAY #402
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6360
Practice Address - Country:US
Practice Address - Phone:972-682-3909
Practice Address - Fax:972-682-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y500OtherMEDICARE GROUP
TX0074QGOtherBCBS
TX12249902Medicaid
TXJ3092OtherSTATE LICENCE NUMBER
TXJ3092OtherSTATE LICENCE NUMBER
TX00538LMedicare ID - Type Unspecified