Healthcare Provider Details

I. General information

NPI: 1972823367
Provider Name (Legal Business Name): KEITH ELLIS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 E 1100 N
CHESTERTON IN
46304
US

IV. Provider business mailing address

502 E 1100 N
CHESTERTON IN
46304-9697
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-5850
  • Fax: 219-250-2072
Mailing address:
  • Phone: 219-926-5850
  • Fax: 219-250-2072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05010042A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: