Provider Demographics
NPI:1134165343
Name:ELLIS, CHARLES MICHAEL (PT, ATC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7449 EASTCHASE PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6846
Mailing Address - Country:US
Mailing Address - Phone:334-747-4030
Mailing Address - Fax:334-747-4031
Practice Address - Street 1:2000 BERRY CHASE PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-6896
Practice Address - Country:US
Practice Address - Phone:334-356-6453
Practice Address - Fax:334-239-8126
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL890013760Medicaid