Provider Demographics
NPI:1962464818
Name:ELLIS, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 GENESEE ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2199
Mailing Address - Country:US
Mailing Address - Phone:315-793-8806
Mailing Address - Fax:315-793-8046
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-624-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2093562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010209356OtherBCBS
NY300099765OtherRAIL ROAD MEDICARE
NY01874611Medicaid
NY4199650OtherGHI
NY040426013962OtherFIDELIS
NY960976OtherMVP
NY209356-1OtherWC
NY10037625OtherCDPHP
NY040426013962OtherFIDELIS
NYG74665Medicare UPIN
NY10037625OtherCDPHP