Provider Demographics
NPI:1740349661
Name:JON M. ELLIS, MD PA
Entity type:Organization
Organization Name:JON M. ELLIS, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROHRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-741-1400
Mailing Address - Street 1:7030 NEW SANGER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3991
Mailing Address - Country:US
Mailing Address - Phone:254-774-1140
Mailing Address - Fax:254-741-1428
Practice Address - Street 1:7030 NEW SANGER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3991
Practice Address - Country:US
Practice Address - Phone:254-774-1140
Practice Address - Fax:254-741-1428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9580207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDB8538Medicare PIN
TX00447UMedicare PIN