Provider Demographics
NPI:1922031376
Name:BRUCE E. ELLISON, MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BRUCE E. ELLISON, MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-366-4585
Mailing Address - Street 1:2940 WHIPPLE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2857
Mailing Address - Country:US
Mailing Address - Phone:650-366-4585
Mailing Address - Fax:650-366-3896
Practice Address - Street 1:2940 WHIPPLE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-2857
Practice Address - Country:US
Practice Address - Phone:650-366-4585
Practice Address - Fax:650-366-3896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29131ZMedicare ID - Type UnspecifiedMEDICARE GROUP ID #