Provider Demographics
NPI:1922042225
Name:ELLIE, CARMEN JAY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:JAY
Last Name:ELLIE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:345 COUNTRY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4701
Mailing Address - Country:US
Mailing Address - Phone:585-225-9230
Mailing Address - Fax:585-225-9739
Practice Address - Street 1:191 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1150
Practice Address - Country:US
Practice Address - Phone:585-235-1514
Practice Address - Fax:585-426-4997
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191341-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110179566OtherRRM LEGACY#
NY000523980003OtherBCBS
NY01487365Medicaid
NYP00392597OtherRAILROAD
NY110179566OtherRRM LEGACY#
NY01487365Medicaid