Provider Demographics
NPI:1205955937
Name:STEVEN S. ELLINGER, OD, PLC
Entity type:Organization
Organization Name:STEVEN S. ELLINGER, OD, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-329-1030
Mailing Address - Street 1:1612 E CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-4410
Mailing Address - Country:US
Mailing Address - Phone:269-329-1030
Mailing Address - Fax:269-329-0966
Practice Address - Street 1:1612 E. CENTRE AVE.
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4410
Practice Address - Country:US
Practice Address - Phone:269-329-1030
Practice Address - Fax:269-329-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB4444X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU73526Medicare UPIN
MI5599300001Medicare NSC
MIOP28110Medicare PIN