Healthcare Provider Details

I. General information

NPI: 1477180339
Provider Name (Legal Business Name): JOSHUA SHAW ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

127 TEN HILLS RD
SOMERVILLE MA
02145-1031
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2800
  • Fax:
Mailing address:
  • Phone: 803-587-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number293661
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: