Healthcare Provider Details

I. General information

NPI: 1154322741
Provider Name (Legal Business Name): PANAYIOTIS A ELLINAS II MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 5TH ST CQCH BILLING DEPT
DOUGLAS AZ
85607-2859
US

IV. Provider business mailing address

101 COLE AVE CQCH BILLING DEPT
BISBEE AZ
85603-1327
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-7659
  • Fax:
Mailing address:
  • Phone: 520-432-6452
  • Fax: 520-432-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23114
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: