Provider Demographics
NPI:1932254083
Name:ELLISON, CRAIG M (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE #305
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-751-5763
Practice Address - Fax:703-370-8704
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234566207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00777103OtherRR MEDICARE
VA1932254083Medicaid
VA1932254083Medicaid
DCP00777103OtherRR MEDICARE
VA017321D12Medicare ID - Type Unspecified