Healthcare Provider Details

I. General information

NPI: 1619081155
Provider Name (Legal Business Name): PATRICK MICHAEL ELLISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 BAYSHORE BLVD
TAMPA FL
33621-1607
US

IV. Provider business mailing address

1329 LUSITANA ST 501
HONOLULU HI
96813-2412
US

V. Phone/Fax

Practice location:
  • Phone: 813-827-9548
  • Fax: 813-828-5731
Mailing address:
  • Phone: 808-521-1102
  • Fax: 808-521-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD-18276
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: