Healthcare Provider Details

I. General information

NPI: 1457315590
Provider Name (Legal Business Name): JODY ELLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD RADIOLOGY DEPARTMENT
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

9201 CALUMET AVE
MUNSTER IN
46321-2807
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-4569
  • Fax:
Mailing address:
  • Phone: 219-836-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1000818A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: