Healthcare Provider Details

I. General information

NPI: 1376898122
Provider Name (Legal Business Name): ELLIS CHRISTIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N LAWNWOOD CIR
FORT PIERCE FL
34950-4884
US

IV. Provider business mailing address

1700 SE HILLMOOR DR STE 407
PORT ST LUCIE FL
34952-7561
US

V. Phone/Fax

Practice location:
  • Phone: 772-302-3977
  • Fax: 772-673-8502
Mailing address:
  • Phone: 772-335-9600
  • Fax: 772-398-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125061363
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME139552
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME139552
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: