Provider Demographics
NPI:1184870164
Name:ENRIQUE ELLENBOGEN, M.D. INC
Entity type:Organization
Organization Name:ENRIQUE ELLENBOGEN, M.D. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-335-7121
Mailing Address - Street 1:700 S STANFIELD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2569
Mailing Address - Country:US
Mailing Address - Phone:937-335-7121
Mailing Address - Fax:937-335-7124
Practice Address - Street 1:700 S STANFIELD RD
Practice Address - Street 2:SUITE B
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2569
Practice Address - Country:US
Practice Address - Phone:937-335-7121
Practice Address - Fax:937-335-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100246261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHD00246OtherHUMANA
OHL0277598Medicaid
OH000000010310OtherANTHEM
OHD00246OtherHUMANA
OHL0277598Medicaid
OH0243720002Medicare NSC