Healthcare Provider Details

I. General information

NPI: 1336631720
Provider Name (Legal Business Name): GREGORY S ELLIS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 YORK RD STE 104
TOWSON MD
21204-7446
US

IV. Provider business mailing address

8322 BELLONA AVE STE 100
TOWSON MD
21204-2065
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-4024
  • Fax: 443-991-4582
Mailing address:
  • Phone: 410-337-7900
  • Fax: 410-769-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27007
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier27007
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerPT LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: