Healthcare Provider Details

I. General information

NPI: 1740231455
Provider Name (Legal Business Name): JASON M ELLISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY ST STE 200
BOISE ID
83704
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-4600
  • Fax: 208-302-4655
Mailing address:
  • Phone: 208-302-4600
  • Fax: 208-302-4655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM10380
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberM-10380
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: