Provider Demographics
NPI:1972777928
Name:DR JOHN P ELLIS CLINIC PODIATRY LLC
Entity Type:Organization
Organization Name:DR JOHN P ELLIS CLINIC PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-333-7300
Mailing Address - Street 1:4758 RIDGE RD
Mailing Address - Street 2:STE 161
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3327
Mailing Address - Country:US
Mailing Address - Phone:440-235-8484
Mailing Address - Fax:440-235-8440
Practice Address - Street 1:21992 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3333
Practice Address - Country:US
Practice Address - Phone:440-333-7300
Practice Address - Fax:440-235-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002463E213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0691845Medicaid
OH0691845Medicaid
T80656Medicare UPIN
OH0607228Medicare PIN