Healthcare Provider Details

I. General information

NPI: 1558441790
Provider Name (Legal Business Name): JAY M ELLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WENDELL AVE
PITTSFIELD MA
01201-6941
US

IV. Provider business mailing address

100 WENDELL AVE
PITTSFIELD MA
01201-6941
US

V. Phone/Fax

Practice location:
  • Phone: 413-499-7128
  • Fax: 413-447-1926
Mailing address:
  • Phone: 413-499-7128
  • Fax: 413-447-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number40812
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: