Provider Demographics
NPI:1336204171
Name:ELLIS, MARK J
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-5037
Mailing Address - Country:US
Mailing Address - Phone:301-714-0200
Mailing Address - Fax:301-739-8533
Practice Address - Street 1:1101 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-5037
Practice Address - Country:US
Practice Address - Phone:301-714-0200
Practice Address - Fax:301-739-8533
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDYM005079L2278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0391030001Medicare ID - Type Unspecified