Healthcare Provider Details

I. General information

NPI: 1679768675
Provider Name (Legal Business Name): TERENCE B ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10537 S EWING AVE LOWER LEVEL
CHICAGO IL
60617-6220
US

IV. Provider business mailing address

10537 S EWING AVE LOWER LEVEL
CHICAGO IL
60617-6220
US

V. Phone/Fax

Practice location:
  • Phone: 312-212-4570
  • Fax: 773-734-0407
Mailing address:
  • Phone: 312-212-4570
  • Fax: 773-734-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246X00000X
TaxonomyCardiovascular Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: