Healthcare Provider Details

I. General information

NPI: 1700316403
Provider Name (Legal Business Name): BRIAN ALLEN ELLISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11055 LAS VEGAS BLVD S
LAS VEGAS NV
89183-5403
US

IV. Provider business mailing address

PO BOX 202450
DALLAS TX
75320-2450
US

V. Phone/Fax

Practice location:
  • Phone: 877-406-2916
  • Fax: 800-656-0593
Mailing address:
  • Phone: 877-656-2916
  • Fax: 800-656-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25IA13189500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number281766
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA183776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: