Provider Demographics
NPI:1720057755
Name:ELLIS, JOHN M (MD)
Entity Type:Individual
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First Name:JOHN
Middle Name:M
Last Name:ELLIS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:RM 339
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:70 EAST STREET
Practice Address - Street 2:VALLEY REGIONAL MEDICAL SERVICES
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844
Practice Address - Country:US
Practice Address - Phone:978-688-0773
Practice Address - Fax:978-681-6173
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-02-23
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Provider Licenses
StateLicense IDTaxonomies
MA585462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3032701Medicaid
MA3032701Medicaid
MAB74939Medicare UPIN