Provider Demographics
NPI:1780243451
Name:ELLINGWORTH, JUSTIN ROSS (CAA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROSS
Last Name:ELLINGWORTH
Suffix:
Gender:M
Credentials:CAA
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Mailing Address - Street 1:950 N MERIDIAN ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-9981
Practice Address - Fax:317-944-0282
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN75000041A367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant